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HANDBOOK 

OF 

MEDICAL  Treatment 


EDITED    BY 

JOHN  C.  Da  COSTA,  Jr.,  M.D. 

Associate  Professor  op  Medicine,  Jefferson  Medical  Collkgi 
Philadelphia 


"WITH    THE    ACTIVE    CO-OPERATION 
of 

FOURTEEN    ASSOCIATE    EDITORS 


IN     TWO     VOLUMES 
VOLUME  ONE 

ILL  U  ST  R  A  TED 


WITH    AN   INTRODUCTION 

BY 

WILLIAM  W.  KEEN,  M.D.,  LL.D.,  Hon.  F.A.C.S. 

Emeritus  Professor  of  Sdrgerv,  Jefferson  Medical 
College,  Philadelphia 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  Publishers 

English  Depot 
Stanley  Phillips,  London 

1919 


"      -  ^ol  €0 
x_inrto  • 

COPYRIGHT,  1919 

BY 
F.  A.  DAVIS   COMPANY 


Copyright,  Great  Britain.     All  Rights  Reserved 


PRESS   OF 

F.    A.     DAVIS    COMPANY 

PHILADELPHIA.   U.  S.  A. 


INTRODUCTION. 


One  of  the  pleasures  of  an  old  teacher  is  to  see  his  pupils 
growing  in  usefulness  and  service  to  our  profession  and  to  the 
community.  Among  the  Associate  Editors  of  Da  Costa's  book 
are  several  of  my  old  pupils,  including  in  this  pleasant  com- 
pany the  highly  esteemed  editor  himself,  in  whose  careers  I 
take  a  genuine  personal  interest  and  a  pedagogic  pride.  Those 
whom  I  have  not  had  the  pleasure  and  honor  of  teaching  I 
have  known  or  known  of,  and  greet  them  as  fellow-authors 
striving  to  elevate  and  instruct  the  younger  and  less  experi- 
enced members  of  the  profession,  and  to  serve  our  Country, 
and  also  to  serve  our  common  Humanity.  It  is  of  interest  to 
note  that  nearly  all  of  the  Associate  Editors  are  already  in 
the  Medical  Corps  of  our  Army,  Navy,  or  Public  Health  Ser- 
vice. The  few  not  so  enrolled  have  reasons  valid  to  their  con- 
sciences or  to  their  countrymen. 

I  have  seen  all  the  proofs  of  the  first  volume,  and  so  far  as 
a  surgeon  can  judge,  it  bids  fair  to  be  of  very  great  practical 
value.    The  second  volume,  I  hope,  will  be  its  chief  rival. 

W.  W.   Keen. 


(Hi) 


PREFACE. 


This  book  represents  the  correlated  efforts  of  a  represen- 
tative group  of  Philadelphia  medical  teachers  and  hospital 
workers  to  present  the  principles  of  modern  medical  treatment 
in  an  authoritative  manner.  The  endeavor  has  been  made  to 
prepare  a  practical  working-  manual,  unburdened  by  technicali- 
ties, free  from  useless  tradition,  and  expressed  with  a  direct- 
ness and  simplicity  that  reads  fact  for  theory,  and  succinctly 
expresses  the  various  writers'  statements  as  the  personal 
opinions  and  experiences  of  skilled  consultants. 

The  editor  has  been  most  fortunate  in  having  enlisted  as 
his  associates  in  the  undertaking  the  interest  of  a  staff  whose 
personnel  is  an  earnest  of  an  ex  cathedra  presentation  of  the 
subjects  treated,  and  who  represent  all  that  is  final,  sane,  and 
progressive  in  the  medical  world  today.  Inasmuch  as  the 
intelligent  treatment  of  any  given  disease  must  rest  upon  an 
appreciation  of  the  underlying  pathologic  lesions  and  diagnos- 
tic data,  the  topics  of  clinical  pathology  and  diagnosis  re- 
ceive commensurate  emphasis.  This  makes  for  a  clearer 
understanding  of  the  therapeutic  measures  subsequently  ad- 
vised, which  are  considered  upon  the  tangible  basis  of 
pathologic  cause.  Laboratory  technic  and  complete  clinical 
descriptions,  not  being  germane  to  the  plan  of  this  work,  are 
omitted  save  when  their  inclusion  seems  helpful  to  certain  de- 
tails of  treatment. 

The  subjects  dealt  with  are  those  of  interest  to  the  prac- 
titioner of  internal  medicine,  and  do  not  primarily  concern 
the  surgeon  or  the  specialist.  The  classification  of  diseases  is 
that  generally  conceded  as  most  acceptable,  but  certain  arbi- 
trary exceptions  to  this  general  rule  are  made,  notably  in  the 
acute  infections,  exanthemata,  and  tropical  diseases,  in  order 

(V) 


VI 


PREFACE. 


thus  to  obtain  the  personal  opinion  of  the  author  best  qualified 
to  direct  the  care  of  these  disorders. 

The  editor  is  under  obligations  to  the  W.  B.  Saunders 
Company  and  to  P.  Blakiston  &  Sons  Company  for  permission 
to  use  illustrations  from  his  published  works  on  Physical  Diag- 
nosis and  Clinical  Hematology ;  the  latter  firm  has  also  allowed 
the  reproduction  of  the  fig^ures  from  Schott's  monograph  on 
the  Balneogymnastic  Treatment  of  Cardiac  Disease. 

J.  C.  Da  C,  Jr. 


ASSOCIATE  EDITORS. 


FRANK  A.  CRAIG,  M.D., 

Instructor  in  Medicine,  University  of  Pennsylvania;  Visiting  Physician,  Henry 
Phipps  Institute,  University  of  Pennsylvania;  Visiting  Physician,  White  Haven 
Sanatorium;  Physician  in  Charge  of  the  Tuberculosis  Class,  Presbyterian  Hospital. 


JUDSON  DALAND,  M.D., 

Professor  of  Clinical  Medicine,  Graduate  School  of  Medicine,  University  of 
Pennsylvania. 


FRANCIS  X.  DERCUM,  A.M.,  M.D.,  Ph.D., 

Professor  of  Nervous  and  Mental  Diseases,  Jefferson  Medical  College,  Philadelphia; 
Ex-President  of  the  American  Neurological  Association;  Foreiigii  Corresponding 
Member  of  the  Neurological  Society  of  Paris;  Corresiponding  Member  of  the  Neu- 
rological and  Psychiatric  Society  of  Vienna;  Member  of  the  Royal  Medical  Society 
of  Budapest;   Consulting  Neurologist  to  the  Philadelphia  General  Hospital,  etc. 


CLIFFORD  B.  FARR,  A.M.,  M.D., 

Associate  in  Medicine,  University  of  Pennsylvania;  Assistant  Visiting  Physician, 
Philadelphia  General  Hospital;  Professor  of  Diseases  of  the  Stomach  and  Intes- 
tines, Philadelphia  Polyclinic;  Formerly  Pathologist,  Presbyterian  Hospital,  Phil- 
adelphia, 


M.  HOWARD  FUSSELL,  M.D., 

Professor  of  Applied  Therapeutics,  University  of  Pennsylvania;  Physicianj  to  the 
University  Hospital,  the  Episcopal,  St.  Timothy's,  and  St.  Mary's  Hospitals, 
Philadelphia. 


VICTOR  G.  HEISER,  M.D.,  D.Sc, 

Director  for  the  East,  International  Health  Board,  Rockefeller  Foundation;  For- 
merly Director  of  Health  for  the  Philippine  Islands,  and  Professor  of  Hygiene 
and  Sanitation,  College  of  Medicine  and  Surgery,  University  of  the  Philippines. 


J.  NORMAN  HENRY,  M.D., 

Visiting  Physician,  Pennsylvania  Hospital;  Formerly  Clinical  Professor  of  Medicine, 
Woman's  Medical  College  of  Pennsylvania;  Formerly  Assistant  Physician,  Phil- 
adelphia Hospital. 


(Vii) 


viii  ASSOCIATE   EDITORS. 


WILMER   KRUSEN,   M.D.,    LL.D.,    F.A.C.S., 

Professor  of  Gynecology,  Temple  University  of  Philadelphia,  Department  of  Medi- 
cine; Chief  Gynecologist,  Samaritan  Hospital;  ^Gynecologist,  Garretson  Hospital; 
Director,  Department  of  Public  Health  and  Charities,  Philadelphia. 


B.  B.  VINCENT  LYON,  A.B.,  M.D., 

Chief  of   Clinic,    Gastro-enterological   Department,    Jefferson    Hospital;    Pathologist, 
Methodist  Episcopal  Hospital,   Philadelphia. 


HENRY  K.  MOHLER,  M.D., 

Medical  Director,  Jefferson  Hospital,  Philadelphia. 

RALPH  PEMBERTON,  M.S.,  M.D., 

Physician  to  the  Presbyterian  Hospital,  Philadelphia. 

CHARLES  E.  de  M.  SAJOUS,  MD.,  LL.D.,  Sc.D., 

Fellow  of  the  College  of  Physicians  and  of  the  American  Philosophical  Society; 
Professor  of  Therapeutics,  Temple  University  of  Philadelphia,  Department  of 
Medicine. 

S.  CALVIN  SMITH,  Sc.M.,  M.D., 

Instructor  in  Medicine,  Jefferson  Medical  College;   Acting  Chief  Clinical  Assistant, 
Medical  Clinic,  Jefferson  Hospital,  Philadelphia. 

SAMUEL  S.  WOODY,  M.D., 

Chief  Resident  Physician,  Philadelphia  Hospital  for  Contagious  Diseases. 


CONTENTS 

VOLUME  I. 


PAGE 

Specific  Infections, 3 

By  M.  Howard  Fussell,  M.D. 

Typhoid  Fever,  3;  Paratyphoid  Fever,  27;  Croupous  Pneumonia,  27;  Catar- 
rhal Pneumonia,  43;  Pyogenic  Infections,  47;  Colon-bacillus  Infections, 
50;  Diphtheria,  51;  Erysipelas,  65;  TuberculosiSi,  68;  Syphilis,  76;  Grono- 
coccus  Infections,  86;  Influenza,  89;  Cerebrospinal  Fever,  95;  Tetanus, 
98;  Glanders.  101;  Anthrax,  102;  Whooping-cough,  104;  Rocky  Mountain 
Spotted  Fever,  108;  Parotitis,  110;  Poliomyelitis,  111;  Rheumatic  Fever, 
113;  Tonsillitis,  123;  Febricula,  124;  Infectious  Jaundice,  125;  Glandular 
Fever,  126;  Actinomycosis,  126;  Helminthiasis,  127;  Parasitic  Insects, 
140;  Rabies,  144;  Psittacosis,  146;  Milk  Sickness,  146;  Foot-and-mouth 
Disease,  147;  Infectious  Colds,  148;  Miliary  Fever,  149. 


Exanthemata, 153 

By  Samuel  S.  Woody,  M.D. 

Smallpox,    156;    Varioloid,    160;    Vaccination,    160;    Varicella,    162;    Scarlet 
Fever,  165;  Measles,  179;  German  Measles,  183. 


Tropical  Diseases,         .       .       .       .       .       .     187 

By   Victor   G.   Heiser,   M.D.,    D.Sc. 

Leprosy,  187;  Malarial  Fever,  205;  Yellow  Fever,  239;  Dengue,  247;  Malta 
Fever,  250;  Cholera,  256;  Beriberi,  273;  Trypanosomiasis,  286;  Hookworm 
Infection,  289;  The  Dysenteries,  303;  Rat-bite  Fever,  325;  Relapsing 
Fever,  328;  Frambesia,  332;  Oriental  Sore,  342;  Sprue,  344;  Leishma- 
niasis, 352;  Typhus  Fever,  359;  Bubonic  Plague,  366;  Filariasis,  382; 
Filarial  Lymphangitis,  390;  Elephantiasis,  391. 


The  Intoxications, 405 

By  Henry  K.  Mohler,  M.D. 

General  Considerations,  406;  Principles  of  Treatment  of  Poisoning,  412; 
Mercurial  Poisoning,  415;  Arsenic  Poisoning,  418;  Lead  Poisoning,  421; 
Phosphorus  Poisoning,  423;  Copper,  Zinc,  and  Tin  Poisoning,  425;  Silver* 
Poisoning  or  Argyria,  426;  Illuminating  Gas  Poisoning,  427;  Cocainlsm, 
430;  Opium  Poisoning,  433;  Alcoholism,  438;  Food  Poisoning,  448;  Sun- 
stroke, 444. 

(ix) 


X  -  CONTENTS. 

PAGE 

Diseases  of  Metabolism  and  Nutrition,  .       .     449 

By   Clifford   B.   Faer,   A.M.,    M.D.,   and 
Ralph  Pemberton,  M.S.,  M.D. 

General  Considerations,  449;  Scurvy  in  Adults,  463;  Infantile  Scurvy,  468; 
Rickets,  471;  Congenital  Rickets,  476;  Late  Rickets,  476;  Obes.ity,  477; 
Gout,  496;  Diabetes  Mellitus,  515;  Diabetes  Insipidus,  537;  Arthritis,  541; 
Primary  Hypertrophic  Osteoarthritis,  543;  Infectious  Arthritis,  543; 
Primary  Progressive  Polyarthritis,  559;  Chronic  Villous  Arthritis,  568; 
Chronic  Arthropathies  of  the  Spine,  568;  Still's  Disease,  569;  Heber- 
den's  Nodes,  569;   Subcutaneous  Fibroid  Nodules,  570. 


Diseases  of  the  Nervous  System,        .        .        .     577 

By   Francis   X.    Dercum,   A.M.,    M.D.,    Ph.D.,   and 
Sherman  F.  Gilpin,  M.D. 

Part  I.— Functional  Diseases,  577:  Neurasthenia,  578;  Hysteria,  589;  Neu- 
rasthenoid  States,  604;  Hypochondria,  606;  Headache,  608;  Migraine,  612; 
Vertigo,  615;  Epilepsy,  618;  Infantile  Convulsions,  622;  Puerperal  Con- 
vulsions, 625;  Chorea,  626;  Huntingdon's  Chorea,  628;  Electric  Chorea, 
630;  Tic,  631;  Habit  Spasm,  632;  Localized  Myospasms,  633;  Spasmodic 
Torticollis,  636;  Occupation  Neuroses,  641;  Myasthenia  Gravis,  642; 
Tetany,  644;  Paralysis  Agitans,  647;  Functional  T'remors,  649.  Part  II,— 
Organic  Diseases,  651:  Diseases  of  the  Dura  Mater,  651;  Acute  Cerebral 
Leptomeningitis,  653;  Hydrocephalus,  655;  Brain  Abscess,  655;  Throm- 
bosis of  Cerebral  Sinuses,  657;  Cerebral  Anemia,  657;  Cerebral  Hyper- 
emia, 658;  Cerebral  Apoplexy,  659;  Brain  Tumor,  662;  Disieases  of  the 
Spinal  Cord,  664;  Hereditary  Spastic  Paraplegia,  667;  Spastic  Paralysis 
of  Infants  and  Children,  668;  Primary  Lateral  Sclerosis,  669;  Acute  An- 
terior Poliomyelitis,  670;  Acute  Bulbar  Paralysis,  673;  Progressive  Mus- 
cular Atrophy,  674;  Chronic  Progressive  Bulbar  Palsy,  675;  Amyotrophic 
Lateral  Sclerosis,  676;  Ataxic  Paraplegia,  676;  Hereditary  Ataxia,  677; 
Spinal  Meningeal  Hemorrhage,  678;  Embolism  and  Thrombosis,  679; 
Myelitis,  679;  Acute  Myelitis,  679;  Compression  of  the  Spinal  Cord,  681  ;i 
Chronic  Myelitis,  682;  Syringomyelia,  682;  Acutei  Ascending  (Landry's) 
Paralysis,  683;  Multiple  Sclerosis,  684;  The  Muscular  Dystrophies,  685; 
Progressive  Neuritic  Muscular  Atrophy,  686;  Syphilis  of  the  Nervous 
System,  687;  Pressure  Palsy,  694;  Neuritis,  694;  Local  Neuritis,  695;  Mul- 
tiple Neuritis,  696;  Neuralgia,  698;  The  Fifth  Nerve,  699;  The  Seventh 
Nerve,  701;  Brachial  Plexus,  703;  Affections  of  Individual  Arm  Nerves, 
705;  Dorsal  Nerves,  705;  Lumbar  and  Sacral  Nerves,  705;  Coccygodynia, 
708;  Vasomotor  and  Trophic  Diseases' — Raynaud's  Disease,  708;  Angio- 
neurotic Edema,  710;  Intermittent  Claudication,  711;  Progressive  Facial 
Hemiatrophy,  712;  Scleroderma,  713;  Brythromelalgia,  715;  Acropares- 
thesia, 715;  Hypertrophic  Pulmonary  Osteoarthropathy,  716;  Leontiasis 
Ossea,  717;  Osteitis  Deformaas,  717;  Adiposis  Dolorosa,  718. 


Specific  Infections 

BY 

M.    HOWARD   FUSSELL,    M.D., 

Professor  of  Applied  Therapeutics,  University  of  Pennsylvania;  Phy- 
sician to  the  University  HospLtal,  the  Episcopal,  St.  Timothy's, 
and  Chestnut  Hill  Hospitals. 


(n 


Specific  Infections. 


FOREWORD. 

The  section  on  the  Specific  Infections  has  been  written 
with  the  hope  and  the  expectation  that  it  will  prove  helpful  to 
the  practitioner  of  medicine,  and  to  this  end  the  subject  matter 
has  been  freed  of  technicalities  as  far  as  possible.  Sufficient 
reference  to  clinical  pathology  and  bacteriology  has  been  made 
to  give  the  reader  a  clear  idea  of  the  etiology  of  the  various 
diseases  considered,  and  to  furnish  a  stable  groundwork  for 
the  therapeutic  measures  advocated. 

The  treatment  of  the  infectious  diseases  here  described  is 
based  upon  the  writer's  understanding  of  their  clinical  fea- 
tures, and  in  many  instances  the  methods  given  represent  his 
own  plan  of  management  in  the  circumstances  met  with.  This 
course  has  been  determined  by  his  personal  experience,  supple- 
mented by  a  rather  wide  consultation  of  the  current  literature, 
but  originality  is  disclaimed,  save  that  which  naturally  may  be 
ascribed  to  one's  practical  experience  in  the  ward  and  in  the 
sick-room. 

To  the  authors  of  numerous  standard  textbooks  and 
monographs  the  writer  owes  much  of  the  information  here- 
with presented,  and  it  has  been  his  endeavor  to  give  credit 
in  the  text  for  data  from  these  sources. 

TYPHOID    FEVER. 

In  the  management  of  typhoid  fever  one  must  have  as  fair 
an  understanding  as  possible  of  the  cause,  the  pathology,  and 
the  means  of  its  transmission  from  one  individual  to  another. 

The  specific  cause  of  typhoid  fever  is  a  motile  bacillus, 
the  Bacillus  typJiosits,  or  Ebertli's  bacillus,  a  micro-organism 
which,  after  gaining  lodgement  in  the  body,  attacks  especially 
the  lymphoid  tissue,  and  almost  without  exception  the  lym- 
phatic glands,  solitary  glands  and  Pyer's  patches  of  tlie  small 

(3) 


4  SPECIFIC   INFECTIONS. 

intestine,  and  also  the  lymph-glands  in  the  cecum  and  in  the 
first  part  of  the  large  intestine. 

There  is  a  general  engorgement  and  enlargement  of  the 
lymph-glands,  especially  of  the  mesenteric  group,  and  of  the 
spleen.  There  is  a  demonstrable  bacteremia  during  the  first 
two  weeks  of  the  disease,  but  the  organisms  are  difficult  to 
find  in  the  blood-stream  during  the  later  weeks  of  the  infec- 
tion. After  the  first  fortnight  the  typhoid  subject  becomes 
toxic,  and  the  disease  works  its  greatest  destruction  through 
its  toxic  effects,  except  when  localization  of  the  bacteria  in 
such  areas  as  the  lymph-glands  of  the  intestines,  in  the 
larynx,  in  the  lungs,  and  in  other  situations  excites  local  com- 
plications which  may  imperil  the  patient's  life  or  prove  fatal. 

The  typhoid  bacilli  are  found  during  the  disease,  and  often 
long  after  active  symptoms  have  disappeared,  in  both  the 
feces  and  the  urine,  and  have  been  demonstrated  in  the  saliva. 

Knowledge  of  these  latter  facts  is  of  the  utmost  value  to 
everyone,  and  especially  to  the  laity,  because  this  knowledge 
gives  absolute  ability  to  prevent  the  disease. 

The  fact  that  typhoid  fever  is  caused  by  a  micro-organism 
which  is  thrown  off  in  the  feces,  urine  and  saliva  makes  it 
possible  to  lay  down  rules  for  its  absolute  prevention.  It  is 
because  this  certain  knowledge  is  not  universally  applied  to 
every  case  that  typhoid  fever  is  so  prevalent  a  disease,  for 
destruction  and  disinfection  of  all  of  the  excreta  at  their 
source  would,  in  a  short  time,  cause  the  absolute  disappear- 
ance of  the  disease. 

Methods  of  Prophylaxis.  Every  case  of  typhoid  fever 
must  be  considered  a  source  from  which  other  cases  may 
arise,  and,  without  exception,  the  typhoid  patient  should  be 
in  the  hands  of  one  or  more  well-instructed  nurses,  or  be 
treated  in  a  hospital.  The  nurse  should  wear  a  wash  gown 
and  rubber  gloves  when  handling  the  patient,  the  bed-cloth- 
ing, or  anything  which  comes  in  contact  with  the  patient. 
When  the  gloves  are  not  in  use  they  should  be  kept  immersed 
in  some  antiseptic  solution.  This  care  on  the  part  of  the 
nurse  will  prevent  her  from  contracting  the  disease  and  com- 
municating it  to  others. 

The  feces  should  at  once  be  disinfected,  as  soon  as  passed. 
The  bed-pan  should  contain  either  a  10  per  cent,  solution  of 


TYPHOID    FEVER.  5 

phenol  or  chlorinated  lime,  or  the  feces  should  be  mixed  with 
an  equal  bulk  of  boiling  water.  If  an  antiseptic  is  used  it 
should  be  thoroughly  mixed  with  the  feces,  and  the  mixture 
allowed  to  stand  half  an  hour  before  being  emptied  into  the 
hopper.  This  disinfection  should  be  extremely  carefully  done, 
if  an  ordinary  privy-well  is  connected  with  the  house. 

The  same  care  should  be  taken  in  disinfecting  the  urine, 
for  it  is  certain  that  this  excretion  contains  active  bacilli.  An 
additional  method  of  sterilizing  the  urine  is  to  administer  to 
the  patient  5  grains  (0.324  Gm.)  of  hexamethylenamin  (uro- 
tropin)  three  times  a  day,  during  the  whole  course  of  the 
illness. 

All  discharges  from  the  mouth,  including  the  expectora- 
tion, should  be  collected  on  bits  of  cloth  and  immediately 
burned,  or  these  bits  of  infected  material  may  be  put  in  a 
paper  container,  and  this  burned  at  the  first  opportunity. 

All  bed-linen  is  to  be  placed  in  a  disinfecting  solution  and 
boiled  before  being  put  through  the  common  laundry.  All 
unused  food  should  be  burned  or  otherwise  thoroughly  dis- 
infected. Any  utensils  used  in  the  sick-room  should  be  im- 
mersed in  a  disinfecting  solution  and  boiled  before  being 
washed  with  the  ordinary  dishes,  or  handled  by  anyone  except 
the  nurse. 

As  stated  above,  if  these  rules  were  carried  out  in  all 
cases,  typhoid  fever  would  soon  become  an  unknown  disease. 
Unfortunately,  however,  all  cases  are  not  observed  in  the  first 
few  days ;  some  are  not  observed  for  a  long  time,  and  unques- 
tionably many  cases  are  never  recognized  definitely  as  typhoid 
fever.  This  fact,  together  with  disregard  of  the  well-known 
nursing  rules,  are  the  sources  from  which  isolated  cases  of 
typhoid  fever  are  constantly  arising,  and  these  cases,  through 
the  medium  of  drinking-water  and  contaminated  food-supply, 
are  multiplied,  so  that  typhoid  fever  is  an  endemic  disease. 
It  is  a  well-known  fact  that  well-regulated  cities  with  filtered 
or  otherwise  purified  water,  a  clean  food-supply,  and  a  good 
sewage-disposal  plant  are  much  less  likely  to  be  sources  of 
infection  from  typhoid  fever  than  the  "health}-"  country, 
where  there  is  no  sewage,  and  where  dejecta,  often  not  dis- 
infected, are  disposed  of  in  open  privies,  close  to  the  well 
which  supplies  the  drinking-water,  while  the  milk  is  supplied 


6  SPECIFIC    INFECTIONS. 

from  dairies  that  are  either  badly  inspected  or  not  inspected 
at  all.  Thus,  at  the  end  of  every  vacation  season  there  is  a 
more  or  less  severe  epidemic  of  typhoid  fever  in  the  cities  to 
which  have  returned  vacationists  w^ho  have  sojourned  during 
the  summer  in  localities  infected  in  this  manner. 

Purification  of  the  water-supply  is  perhaps  the  most  im- 
portant single  factor  in  the  prevention  of  epidemics  of  typhoid 
fever.  Only  one  instance  of  this  need  be  mentioned.  Phila- 
delphia was  supplied  with  infected  water  from  the  Delaware 
and  Schuylkill  Rivers  until  1906.  Previous  to  the  supply  of 
filtered  water  to  all  citizens  in  Philadelphia  the  deaths  from 
typhoid  fever  ranged  between  666  and  1063  per  annum.  Since 
filtered  water  has  been  used  the  yearly  number  of  deaths  has 
steadily  decreased,  until  in  1910,  there  were  270  deaths,  and 
about  20  per  cent,  of  these  were  traceable  as  to  the  origin  of 
the  case  to  communities  outside  of  Philadelphia. 

When  one  is  not  sure  of  the  purity  of  the  water  one  is 
forced  to  use,  all  water  should  be  boiled.  Another  fertile 
method  by  which  the  disease  is  spread  is  milk.  In  some  cities, 
a  law  more  or  less  adequately  carried  out,  demands  that  all 
milk  dispensed  jpy  dealers  should  be  pasteurized  before  being 
sold.  Individuals  who  are  uncertain  of  the  cleanliness  of 
their  milk  should  always  pasteurize  their  individual  milk- 
supply. 

Insects,  especially  flies,  are  fertile  means  of  infection. 
They  gain  access  to  infected  material,  especially  to  the  feces, 
their  feet  become  covered  with  this  material,  they  then  crawl 
over  food  about  to  be  eaten,  and  hence  the  germs  are  carried 
directly  to  the  person  eating  the  food. 

Two  lessons  are  to  be  learned  from  this :  First,  every  pos- 
sible precaution  must  be  taken  to  disinfect  feces,  urine  and 
sputum  ;  and,  second,  the  sick  individual  must  be  in  a  screened 
room,  in  order  to  prevent  the  flies  getting  to  the  original 
rource  of  the  infection,  the  patient. 

Shellfish,  and  fresh,  uncooked  vegetables,  such  as  lettuce 
and  various  greens,  are  possible  sources  of  infection. 

Last,  but  by  no  means  least,  is  the  typhoid  carrier,  by 
which  is  meant  an  individual  who  is  constantly  discharging 
from  the  intestinal  tract  living  typhoid  bacilli.  The  obvious 
lesson  here  is  to  see  that  both  urine  and  feces  are  free  from 


TYPHOID   FEVER.  7 

typhoid  bacilli  before  the  patient  is  discharged.  This,  of 
course,  can  be  done  through  the  established  laboratories  com- 
mon throughout  the  country. 

Sir  Almroth  Wright,  during  the  Boer  War,  attempted 
to  immunize  the  British  Army  by  means  of  the  killed  bodies 
of  typhoid  bacilli.  This  particular  attempt  at  prophylactic 
vaccination  failed  in  its  effects,  probably  because  of  some 
error  of  technic,  but  later  attempts  have  been  most  success- 
ful. In  1913,  among  the  90,000  American  troops  serving 
in  all  parts  of  the  world,  there  was  not  a  single  death  from 
typhoid  fever  in  all  this  number.  The  figures  of  the  present 
European  War,  and  of  the  mobilized  American  troops  on  the 
Mexican  border  are  not  yet  available,  but  it  is  reported  that 
during  the  first  months  of  the  European  War,  before  all  the 
hastily  assembled  English  forces  were  vaccinated,  typhoid 
fever  was  a  very  common  source  of  disability. 

It  has  been  proved  repeatedly  that  concentrated  amounts 
of  living  bacilli  ingested  by  a  person  who  has  been  vacci- 
nated can  produce  typhoid  fever  in  the  inoculated  subject. 
Hence,  we  must  be  careful  in  all  the  more  familiar  precau- 
tions of  prophylaxis,  and  not  neglect  them  because  we  have 
a  potent  preventive  in  vaccination. 

Vaccination  is  most  valuable,  and  should  be  employed 
even  more  largely  than  it  is  at  present,  but  it  should  not  be 
used  to  the  exclusion  of  methods  which  destroy  the  disease 
at  its  source. 

Prophylaxis,  then,  aside  from  preventive  vaccination,  con- 
sists, briefly,  of  the  recognition  of  cases  of  typhoid  fever  in 
the  very  earliest  stage,  of  careful  nursing,  of  the  disinfection 
of  all  excreta,  of  the  use  of  uncontaminated  water,  milk, 
vegetables  and  shellfish,  and  of  screening  of  the  patient  and 
excreta,  so  that  flies  and  other  insects  may  not  carry  typhoid 
germs  to  the  food. 

TREATMENT. 

Complete  rest,  careful  nursing,  sufiicient  and  Avell-selected 
food,  control  of  the  temperature,  and  early  recognition  and 
treatment  of  complications,  with  the  possible  use  of  typhoid 
vaccines,  are  the  main  points  upon  which   one  can  rely  to 


8  SPECIFIC    INFECTIONS. 

carry  the  patient  through  this  most  treacherous  and  trying 
disease. 

Rest.  This  means  absolute  quiet  in  bed,  the  patient  not 
being  allowed  to  rise  even  for  the  purpose  of  evacuating  the 
bowels  or  for  urinating.  It  is  a  well-known  fact  that  typhoid 
fever  begins  in  various  ways,  gradually  or  suddenly,  and 
often  with  symptoms  suggestive  of  disease  of  special  organs 
in  which  it  is  impossible  to  make  an  early  differential  diag- 
nosis. If  all  such  cases  were  treated  so  far  as  rest  is  con- 
cerned as  though  they  were  typhoid  fever,  one  would  less 
frequently  be  confronted  later  with  a  well-developed  case  of 
typhoid  when  "enteritis"  or  "catarrhal  fever  "  were  thought 
to  be  present. 

It  goes  without  saying  that  an  unremitting  search  for  the 
cause  of  the  symptoms  should  be  made.  This  search  should 
include  repeated  examinations  of  the  blood,  urine  and  feces. 
A  bed-pan  should  be  used  for  feces  and  urine.  By  thus  con- 
serving the  strength  of  the  patient,  complications  may  be 
avoided. 

This  rest  includes,  of  course,  an  abundance  of  sleep. 
Patients  with  typhoid  fever  should  not  be  awakened  for 
food,  drink  or  medicine,  unless  they  are  so  drowsy  from  the 
toxemia  that  they  are  stuporous  and  fall  to  sleep  again 
immediately. 

Efficient  Nursing.  There  is  no  one  element  in  the  treat- 
ment of  typhoid  fever  which  is  of  as  great  value  as  the 
services  of  an  efficient  nurse.  A  well-trained  nurse,  or,  much 
better,  two  nurses,  should  be  in  attendance  on  every  case  of 
this  infection.  If  this,  for  financial  reasons,  is  not  practicable 
in  the  home,  then  the  patient  is  much  better  off  in  a  well- 
regulated  hospital,  where  such  services  are  at  everyone's  call. 
I  have  used  the  term  "well-trained"  in  connection  with  the 
nurse.  I  do  this  because  it  must  be  remembered  that,  while 
the  great  majority  of  hospitals  give  such  a  training  to  their 
nurses  that  the  efficiency  of  their  services  can  be  relied  upon, 
this  is  not  invariably  the  fact,  and,  therefore,  because  the 
physician  must  rely  entirely  upon  a  nurse  to  carry  out  his 
orders,  and  to  watch  for  complications  which  may  appear  sud- 
denly in  the  mildest  cases,  it  becomes  the  physician's  duty  to 
see  that  the  nurse  comes  from  an  institution  in  which  the 


TYPHOID    FEVER.  9 

training  is  adequate,  and  also  to  discover,  if  possible,  the 
character  of  the  individual  nurse  before  she  is  employed. 

It  is  the  duty  of  the  nurse  to  administer  the  food,  to  bathe 
the  patient,  to  administer  the  drugs  according  to  the  direc- 
tions and  orders  of  the  doctor,  and  especially  is  it  her  duty 
to  report  to  the  physician  at  once  any  untoward  circumstance. 
She  should  be  able  to  recognize  symptoms  indicative  of  per- 
foration, hemorrhage,  sudden  cardiac  weakness,  and  similar 
complications,  and  should  at  once  report  them  to  the  phy- 
sician, and  not  presume  to  administer  treatment  herself. 

Food.  The  food  of  typhoid  patients  should  be  of  suffi- 
cient quantity  to  nourish  the  patient,  and  should  be  of  such 
a  character  that  it  can  be  properly  digested  and  will  not 
irritate  the  intestinal  tract. 

Coleman  and  DuBois  have  shown  that  the  metabolism  of 
patients  ill  with  typhoid  is  not  diminished,  and  their  experi- 
ence,, together  with  that  of  many  other  clinicians,  has  proved 
that  food  which  contains  a  daily  intake  of  from  2500  to  3000 
calories  serves  so  to  maintain  the  strength  of  the  patient  that 
he  loses  minimum  weight,  that  his  convalescence  is  much 
hastened,  and  that  complications  are  less  severe. 

A  milk  diet,  which  perhaps  is  the  commonest  administered 
to  a  patient,  in  order  to  be  kept  up  to  the  standard  of  2500  to 
3000  calories  in  twenty-four  hours,  means  that  the  patient 
must  take  from  3  to  4  quarts  (3000  to  4000  mils)  in  each 
twenty-four  hours.  Thus,  if  the  milk  is  given  every  three 
hours,  night  and  day,  he  must  take  12  to  16  ounces  (360  to 
480  mils)  at  each  feeding.  If  the  interval  is  two  hours,  night 
and  day,  the  amount  at  each  feeding  must  be  from  8  to  10 
ounces  (240  to  300  mils)  at  each  feeding.  Anyone  who  has 
attempted  to  force  down  the  throats  of  patients,  even  only 
slightly  ill  with  typhoid  fever,  continuous  doses  of  milk, 
knows  that  it  is  an  impossible  task.  In  the  first  place,  the 
patient  rebels  at  the  large  amount  of  milk,  if  he  be  not  too 
ill  to  rebel,  and  in  the  second  place,  it  is  not  wise  to  awaken 
a  patient  every  two  hours  during  the  day  and  night.  This 
deficient  food  value  of  milk  is  one  of  the  great  objections  to 
its  exclusive  use  as  a  diet  in  typhoid  fever.  This  can  be  over- 
come by  reinforcing  it  with  cream  and  milk-sugar,  thereby 
increasing  its  food  value  so  that  the  quantity   administered 


10  SPECIFIC   INFECTIONS. 

ma}'^  be  much  less,  and  the  food  value  greater  than  when  plain 
milk  is  used.  For  instance,  1  quart  (1000  mils)  of  milk,  750 
calories;  4  ounces  (120  mils)  of  cream,  240  calories;  4  ounces 
(124.4  Gms.)  of  milk-sugar,  240  calories,  making  a  total  of 
1230  calories.  The  following  table,  frequently  used  by  the 
author,  may  be  used  with  very  great  satisfaction : 

6  A.M.    6  ounces  (180  mils)  of  reinforced  milk...     250  calories. 

7  A.M.     Soft    egg,    disli    of    cereal,    1    slice    bread 

and  butter   200 

9  A.M.    6  ounces  (180  mils)  of  reinforced  milk...  250        " 

11  A.M.    6  ounces  (180  mils)  of  reinforced  milk...  250        " 

12  NOON.     Milk    reinforced,     1    baked    or    mashed 

potato,  1  slice  of  bread  and  butter,  or 

toast,  coffee  or  tea 425  " 

2  P.M.    6  ounces  (180  mils)  reinforced  milk 250  " 

4  P.M.    6  ounces  (180  mils)   of  reinforced  milk...  250  " 
6  P.M.     Minced   chicken,    or    junket,    or    soft   part 

of  4  oysters   75  " 

8  P.M.    6  ounces  (180  mils)  of  reinforced  milk. . .  250  " 

2200 
This  combination  will  allow  the  patient  more  than  2000 
calories  of  food  intake,  and  the  amount  will  but  little  exceed 
1  quart  (1000  mils)  of  liquid.  Broths  are  of  little  food  value, 
but  many  patients  are  given  these  liquids,  which  are  grateful, 
but  which  contain  but  little  real  nourishment.  It  is  of  slight 
avail  to  the  patient  if  he  is  given  a  quart  or  so  of  broth ;  his 
desires  are  satisfied,  and  he  is  allowed  to  be  underfed,  think- 
ing himself  overfed.  Milk,  of  course,  can  be  given  in  the  form 
of  junket,  oyster  stews,  and  in  many  other  ways.  It  can  be 
flavored  with  cofifee,  salt,  or  any  flavoring  desired,  in  order 
to  create  a  real  appetite  in  the  patient.  If  one  desires  to  give 
a  liquid  diet  to  the  patient  because  he  is  too  ill  to  eat,  as 
before  stated,  the  main  reliance  must  be  placed  upon  milk. 
Reinforced  milk  will  give  sufficient  nourishment  without 
overburdening  his  stomach  with  liquid. 

When  the  patient  is  able  to  eat,  it  is  well  to  give  him  a 
diet  consisting  of  foods  other  than  milk.  This  lightens  the 
tedium  of  an  exhausting  illness,  helps  to  keep  up  the  strength 
of  the  patient,  and  does  not  nauseate  him  by  its  routine  same- 
ness. For  a  number  of  years  a  liberal  dietary  has  been  used 
by  many  clinicians.     There  is  an  abundance  of  careful  obser- 


TYPHOID    FEVER.  H 

vation  to  show  that  patients  fed  on  liberal  diet  are  at  least 
no  more  prone  to  complications,  and  surely  become  less  toxic, 
than  are  those  on  liquid  diets ;  and,  indeed,  statistics  show- 
figures  in  favor  of  a  mixed  and  free  diet.  The  author's  prac- 
tice is  to  give  a  diet  in  which  reinforced  milk  forms  a  large 
element,  but  which  contains  a  liberal  diet  besides  the  milk. 
The  following  routine  is  ordered,  subject,  of  course,  to  any 
variations  that  seem  necessary.  The  formula  of  the  milk 
mixture  which  gives  a  total  of  1500  calories  can  be  used. 

In  this  way  the  patient  gets  an  abundance  of  food,  is  not 
worried  by  a  monotonous  dietary,  and  is  allowed  to  rest  dur- 
ing the  night.  A  list  of  proper  foods,  taken  from  an  article 
published  by  Frederick  Shattuck,  is  found  below : 

Shattuck  Diet.  1.  Milk,  hot  or  cold,  with  or  without  salt, 
diluted  with  lime-water,  Apollinaris,  or  Vichy.  Peptonized 
milk;  cream  and  water  {i.e.,  less  albumin),  milk  with  white  of 
^gg,  buttermilk,  kumiss,  matzoon,  milk  whey,  milk  with  tea, 
coffee  or  cocoa. 

2.  Soups :  beef,  veal,  chicken,  tomato,  potato,  oyster,  mut- 
ton, pea,  bean,  squash,  carefully  strained  and  thickened  with 
rice,  powdered  arrowroot,  flour,  milk,  cream,  egg  or  barley. 

3.  Horlick's  food,  Mellin's  food,  malted  milk. 

4.  Beef-juice. 

5.  Gruels :  strained  cornmeal,  crackers,  flour,  barley-water, 
toast-water,  albumin-v/ater  with  lemon-juice. 

6.  Ice-cream. 

7.  Eggs,  soft-boiled  or  raw ;  egg-nogg. 

8.  Finely  minced  lean  meat;  scraped  beef,  the  soft  part  of 
raw  oysters ;  soft  crackers  with  milk  or  broth ;  soft  puddings 
without  raisins ;  soft  toast,  without  crust ;  blanc  mange,  wine- 
jelly,  apple-sauce  and  macaroni. 

Ice-cream  may  be  given  in  any  quantity  which  does  not 
cause  nausea  or  diarrhea. 

Care  must  be  taken,  however,  in  the  use  of  such  a  diet  as 
this,  to  see  that  quality  is  not  sacrificed  to  quantity.  It  is  very 
easy  to  satisfy  the  appetite  of  patients  with  typhoid  fever, 
and,  indeed,  they  are  frequently  without  any  appetite,  so  that 
one  must,  by  the  arrangement  of  the  sort  of  diet  shown  above, 
make  it  quite  possible  to  give  enough  in  quantity  as  well  as 
in  quality. 


12  SPECIFIC    INFECTIONS. 

Control  of  the  Temperature.  There  can  be  no  doubt  from 
many  observations  that,  while  fever  is  but  a  symptom  in  the 
course  of  the  disease  of  typhoid  fever,  it  is  a  symptom  v^hich, 
by  itself,  can  do  harm.  It  is  certainly  true  that  the  control 
of  excessive  fever  removes  one  of  the  elements  of  grave  dan- 
ger in  the  disease.  Therefore,  the  application  of  cold  in  one 
wa.y  or  another  is  a  necessary  part  in  the  treatment  of  any 
given  case  w^here  the  fever  continues  at  102)^°  F.  (39.1°  C.) 
or  above. 

Brand's  method  of  cold  plunging  is  still  a  favorite  method 
of  controlling  the  temperature  at  the  hands  of  the  writer. 
This  needs  for  its  application  a  portable  tub  of  some  charac- 
ter, and  hence  its  use  in  a  private  house,  except  where  the 
cost  of  treatment  is  not  a  question  of  importance,  is  imprac- 
ticable. This  is  another  argument  in  favor  of  the  treatment 
of  typhoid  fever  in  a  well-regulated  hospital,  where  a  tub  is 
available  and  skilled  help  to  move  the  patient  in  and  out  of 
the  tub  is  at  hand.  The  writer  believes  that  the  Brand 
method  should  be  used  as  a  routine  procedure  of  hospital 
treatment.  This  belief  is  not  founded  on  fanciful  theories,  but 
is  the  result  of  the  good  efifects  of  a  cold  plunge  upon  patients 
who  have  been  inefficiently  sponged,  or  in  whom  the  tem- 
perature has  been  disregarded.  The  routine  method  of  the 
bath  treatment  is  as  follows : 

The  patient  is  plunged  when  the  axillary  temperature 
reaches  102 3^°  F.  (39.1°  C.)  or  over,  but  not  more  than  eight 
plunges  are  given  in  twenty-four  hours.  A  tub  is  used  which 
is  large  enough  for  the  patient  to  lie  full  length  with  the 
shoulders  and  head  slightly  raised.  The  temperature  of  the 
bath  varies  with  the  reaction  of  the  patient.  Water  at  80°  F. 
(26.6°  C.)  is  a  good  average  temperature  for  the  beginning 
of  the  bath.  If  the  patient  reacts  well,,  the  temperature  of  the 
water  may  be  gradually  lowered  by  the  addition  of  ice  to  the 
bath.  If  he  does  not  react  well,  the  temperature  may  be 
raised  by  the  gradual  addition  of  warm  water.  A  tub  ther- 
mometer should  be  used,  so  as  to  make  the  observations 
accurate,  and  the  nurse  should  not  attempt  to  judge  of  the 
temperature  of  the  bath  water  by  testing  with  the  hands.  Of 
course,  the  water  in  the  tub  should  be  renewed  for  each 
individual  bath.     The  tub  is  wheeled  to  the  side  of  the  bed, 


TYPHOID    FEVER.  13 

the  patient  is  stripped  and  lifted  from  the  bed  by  three 
assistants,  one  taking  the  head  and  shoulders,  the  second  the 
buttocks,  and  a  third  the  feet  and  legs.  For  reasons  of  mod- 
esty, the  patient  should  be  kept  covered  with  a  sheet  or  a 
very  light  blanket  while  being  moved.  After  the  patient  is 
in  the  tub,  the  limbs  and  body  are  rubbed  briskly  by  the 
nurses,  so  as  to  encourage  the  peripheral  circulation.  It  is 
essential  to  see  that  an  ice-cap  is  kept  upon  the  head  of  the 
patient  while  in  the  bath,  in  which  he  remains  for  a  period 
of  from  fifteen  to  twenty  minutes. 

Before  lifting  him  from  the  bath,  the  bed  is  arranged  with 
a  mackintosh  covered  with  a  light  blanket,  upon  which  the 
patient  is  laid  and  rubbed  until  he  is  comfortably  warm. 
Vigorous  rubbing  should  be  restricted  to  the  torso  and  limbs, 
as  no  massage  of  the  abdomen  is  permissible.  Half  an  hour 
to  three-quarters  of  an  hour  after  the  bath  the  temperature 
is  again  taken  and  recorded.  Another  bath  is  given  when  the 
temperature  of  the  patient  reaches  102^°  F.  (39.1°  C.)  again, 
provided  that  an  interval  of  three  hours  has  elapsed  since 
the  beginning  of  the  previous  bath. 

The  effect  of  tubbing  on  the  appearance  and  feelings  of 
the  patient  is  usually  unpleasant.  He  shivers,  the  fingers  and 
lips  may  become  blue,  and  the  radial  pulse  is  difficult  to 
appreciate.  This  dilKculty  in  feeling  the  pulse,  however,  is 
almost  without  exception  the  result  of  muscular  tremor, 
which  makes  it  difficult  to  recognize  the  pulse.  If  the  stetho- 
scope be  placed  over  the  heart,  however,  the  beats  will  be 
found  to  be  regular  and  strong,  and  not  unduly  hurried.  Of 
course,  if  the  heart's  action  becomes  feeble  and  irregular 
(rarely  the  case)  and  the  patient  goes  into  collapse,  he  must 
be  removed  from  the  bath  immediately,  and  at  the  next  occa- 
sion the  bath  water  must  be  of  a  higher  degree  of  tempera- 
ture than  the  one  in  which  the  collapse  occurred.  If  the  bath 
has  been  beneficial,  the  temperature  after  the  bath  will  be 
from  one  to  three  degrees  lower  than  before  the  bath  was 
given ;  the  pulse  will  become  slower,  and,  as  a  rule,  the  patient 
falls  into  a  quiet,  rational  sleep.  The  contraindications  to  the 
bath  are  intestinal  perforation,  intestinal  hemorrhage  and 
collapse.  The  next  best  method  of  applying  cold  in  this  dis- 
ease is  the  form  of  a  cold  affusion. 


14  SPECIFIC  INFECTIONS. 

To  give  this  treatment  properly,  the  bed  should  be  covered 
with  a  rubber  blanket  large  enough  to  extend  over  the  head, 
foot  and  sides  of  the  bed  at  least  one  foot.  Each  corner  of 
this  blanket  is  then  tied,  bringing  a  part  of  its  side  and  ends 
together,  to  form  a  trough  in  which  the  patient  lies.  Water 
of  the  required  temperature  is  then  allowed  to  drip  upon  the 
bare  skin  of  the  patient,  and,  collecting  in  the  blanket,  makes 
a  very  respectable  sort  of  bath.  The  water  is  then  sponged 
from  the  blanket,  and  the  patient  rubbed,  and  covered  with 
a  light  blanket. 

Another  fair  substitute  for  the  Brand  hydrotherapy  is  a 
sponge  hath  given  with  cold  water,  the  patient  being  stripped 
and  the  parts  rubbed.  If  given  after  the  manner  of  a  cleans- 
ing bath  it  will  be  of  little  avail  in  lowering  the  temperature 
of  the  body.  In  order  to  do  this,  which  is  only  one  of  the 
objects  and  the  results  of  the  bath  treatment,  the  water  must 
be  cold  enough  and  the  amount  large  enough  to  attain  those 
objects. 

The  other  object  of  hydrotherapy,  aside  from  lowering  of 
the  temperature  of  the  body,  is  stimulation  of  the  heart's 
action  and  that  of  the  nervous  system.  This  is  a  usual  result. 
Elimination  of  toxins  through  increased  urinary  output  is 
another  one  of  the  good  results  of  the  cold  treatment.  A 
method  of  reducing  temperature  has  been  suggested  by  Wil- 
liams, in  which  the  body  of  the  patient  is  covered  with  gauze 
or  other  thin  material,  over  which  is  sprinkled  tepid  water. 
The  body  is  then  fanned,  either  with  a  hand  fan  or  by  an 
electric  fan,  and  the  evaporation  of  the  water  thus  produced 
cools  the  body.  The  writer  has  not  used  this  method,  but 
he  doubts  whether  it  would  have  all  the  good  results  of  a 
cold  plunge. 

Water  should  be  given  in  abundance,  and  if  a  veritable 
polyuria  can  be  obtained  by  this  means,  much  value  will 
follow. 

Regulation  of  the  bowel  movements  is  a  most  necessary 
part  of  the  treatment.  It  is  a  well-known  fact  that  diarrhea 
is  recognized  as  a  common  symptom  of  the  disease.  On  the 
other  hand,  constipation  is  sometimes  present  from  the  begin- 
ning to  the  end  of  the  disease.  It  is  a  custom  among  prac- 
titioners, when  a  case  of  suspicious  typhoid  fever  presents 


TYPHOID   FEVER.  15 

itself,  to  give  a  preliminary  dose  of  calomel.  This  is  fre- 
quently taught  in  the  various  schools  of  medicine.  In  the 
very  earliest  days  of  the  disease  such  a  routine  measure  is 
permissible,  but  when  there  is  any  doubt  as  to  the  time  the 
disease  has  existed,  it  is  probably  wrong  to  give  a  purgative 
indiscriminately.  In  the  second  or  third  week  a  purgative  is 
harmful  and  not  helpful.  Therefore,  if  during  the  first  few 
days,  up  to  perhaps  the  third  or  fourth  day,  there  appears  to 
be  any  retention  of  material  in  the  bowel  which  is  causing 
irritation,  small  doses  of  calomel  are  permissible,  but  it  should 
not  be  given  as  a  routine.  During  the  active  course  of  the 
disease,  calomel  should  not  be  given,  for  there  is  too  much 
danger  of  causing  hemorrhage  or  perforation  by  a  free  purge. 

Diarrhea  calls  for  treatment  when  there  are  more  than 
three  or  four  bowel  movements  in  twenty-four  hours.  It  is 
treated  according  to  the  cause.  If  it  appears  to  be  the  result 
of  ingested  food,  the  amount  of  food  is  reduced,  or  the  ofifend- 
ihgf  kind  of  food  withdrawn.  If  it  is  the  result  of  the  toxic 
state,  this  is  especiall)^  attended  to  by  reduction  (by  general 
means)  of  that  condition,  as  much  as  possible,  in  a  way  to  be 
spoken  of  later. 

If  it  seems  to  be  the  result  of  retained  material,  flushing 
of  the  lower  bowel  will  be  of  value.  Care  must  be  taken  to 
see  that  the  diarrhea  is  not  a  symptom  of  obstruction,  due  to 
large  fecal  masses  in  the  lower  bowel.  This  complication  can 
be  easily  recognized  by  rectal  examination  of  the  bowel  with 
a  gloved  finger. 

The  diarrhea  may  be  consequent  to  irritation  by  intes- 
tinal ulcers,  and  this  factor  is,  perhaps,  the  commonest  cause. 

The  two  drugs  which  have  been  of  the  greatest  use  to  the 
writer  are  bismuth  and  phenol  salicylate  (salol),  given  in 
doses  of  efficient  size,  combined  with  chalk  mixture.  Such  a 
mixture  as  the  following  is  valuable : 

IJ  Bismuth!  subnitratis   16   (246.8  gr.). 

Phenolis   salicylatis    8   (123.4  gr.). 

Misturas  cretoe  compositi 120   (4  fB). 

M.     S. :     One  teaspoonful   (4  mils)   every  two  liours. 

Useful  Drugs.  As  stated  early  in  this  article,  there  is  no 
specific  drug  for  typhoid  fever.  Therefore,  the  use  of  drugs 
must  be  entirely  symptomatic.     If  there  are  any  drugs  which 


16  SPECIFIC    INFECTIONS. 

are  to  be  used  in  a  routine  method,  those  are  the  mineral  acids 
and  intestinal  antiseptics,  and  the  urinary  antiseptics.  The 
author  is  fond  of  using  a  combination  such  as  follows: 

B  Acidi  hydrochlorici  diluti 16  (246.8  gr.) . 

Tincturse  nucis  vomicae 8  (123.4  gr.). 

Tincturse  gentians  compositi   ....    120   (4  fB) . 
M.     S. :    One  teaspoon ful  (4  mils)  every  three  hours. 

When  the  tongue  becomes  coated  and  thickly  furred,  and 
entire  disgust  for  food  appears,  this  acid  alcoholic  mixture 
seems  to  be  of  decided  value  in  ameliorating  the  symptoms. 

Intestinal  antiseptics  have  appeared  to  me  to  be  of  value 
in  preventing  or  lessening  the  tendency  to  diarrhea  and  tym- 
pany. 

Phenol  salicylate  (salol)  given  in  doses  of  5  grains  (0.325 
Gms.)  every  four  hours  seems  to  be  of  value.  Certainly  the 
fetid  character  of  the  stools  is  frequently  lessened,  and  the 
meteorism  becomes  less  after  the  use  of  this  drug.  Another 
intestinal  antiseptic,  or  one  or  the  other  combinations,  may 
also  be  of  value.  Turpentine  is  of  decided  utility  when  there 
is  much  meteorism,  and  when  the  tongue  is  brown  and  hard 
and  dry.     It  may  be  given  as  an  emulsion. 

I^  Olei  terebinthinae   16  (246.8  gr.) . 

Mucil.  acaciae, 

Aq.  menthse  pip.,  q.  s aa  120  (4  £5). 

Ft.  emulsio. 

S. :     One  teaspoonful   (4  mils)  every  three  hours. 

Alcohol.  This  drug  is  still  used  by  some  practitioners  in 
a  routine  way.  This  is  a  mistake,  for  alcohol  seems  to  be  of 
value  in  certain  conditions,  such  as  an  entire  lack  of  ability 
to  take  food.  But  to  use  it  as  an  actual  heart  stimulant,  is  to 
use  it  in  a  manner  which  is  harmful. 

As  a  food  it  may  be  used  in  the  form  of  whisky  or  brandy 
in  doses  of  2  or  3-  ounces  (60  or  90  mils)  every  twenty-four 
hours.  To  use  it  in  larger  doses  is  to  do  harm.  The  custom 
of  using  6  to  8  ounces  (180  to  240  mils)  of  alcohol  in  twenty- 
four  hours  is  pernicious,  for  it  weakens  the  heart  and  lowers 
the  vitality. 

Cafifein  can  be  used  as  a  cardiac  stimulant,  either  in  the 
form  of  the  alkaloid,  caffein,  or  hypodermically^  as  cafifein 
and  sodium  benzoate. 


TYPHOID    FEVER.  17 

Hexamethylenamin  should  be  resorted  to  as  a  routine  in 
every  case.  It  has  been  shown  by  Gwyn  and  others  that  the 
consistent  use  of  this  drug  throughout  the  disease  tends  to 
keep  the  urine  free  from  typhoid  bacilli. 

Strychnin  should  be  used  in  doses  of  %o  grain  (0.002 
Gm.)  at  intervals  varying  from  eight  to  three  hours.  In  my 
experience  it  is  unwise  to  use  strychnin  in  a  routine  manner 
in  doses  greater  than  just  specified  every  three  hours.  This 
makes  approximately  Y\  grain  (0.016  Gm.)  in  twenty-four 
hours,  and  more  than  this  is  often  accompanied  by  signs  of 
physiologic  action  of  the  drug. 

It  has  been  shown  lately  that  in  certain  cases  of  fever 
digitalis  appears  to  have  exactly  the  same  physiologic  action 
as  when  used  in  cases  of  cardiac  disease,  or  when  used  in  nor- 
mal individuals.  It  is  my  personal  experience,  however,  that 
digitalis  by  the  mouth  or  hypodermically,  when  employed  in 
cases  of  typhoid  fever  with  a  rapid  heart  action  and  failing 
circulation,  is  practically  useless.  The  amount  of  toxin  pres- 
ent in  the  blood  and  affecting  the  heart-muscle  seems  to  ren- 
der the  drug  entirely  useless.  It  seems  much  better  to  depend 
upon  caffein  and  ammonia. 

COMPLICATIONS. 

I  wish  to  add  emphasis  to  the  word  early  in  the  sentence 
used  under  the  heading  of  treatment.  Some  complications, 
such  as  perforation  of  the  bowel  and  laryngeal  perichondritis, 
are  practically  always  fatal  if  not  recognized  early.  Others, 
such  as  a  nephritis  or  cardiac  complications,  acute  dilatation 
of  the  stomach  and  phlebitis  are  treated  much  more  success- 
fully when  recognized  in  the  early  stages  of  their  develop- 
ment. If  left  until  the  full  picture  is  present  they  may  be 
fatal,  when  early  recognition  may  avert  a  serious  or  fatal  issue. 

Perforation  of  the  Bowel.  This  is  a  surgical  complication 
for  which  the  only  practical  cure  is  a  laparotomy.  Every 
pain  in  the  abdomen  of  a  patient  with  typhoid  fever  does  not 
mean  that  the  patient  has  a  perforation  of  the  bowel,  but 
every  abdominal  pain  should  have  the  most  serious  and 
repeated  attention.  If  we  are  to  escape  disaster,  we  must  do 
several  things :  First,  instruct  the  nurse  to  report  at  once  if 
the    patient    complains    of    abdominal    pain ;    second,    see    the 

2 


18  SPECIFIC   INFECTIONS. 

patient  immediately,  whether  the  message  comes  during  the 
day  or  night,  and  then  go  about  making  a  diagnosis  without 
undue  delay.  With  the  patient's  chest  and  abdomen  bared, 
the  chest'should  be  examined  first.  It  must  always  be  remem- 
bered that  a  complicating  pneumonia,  with  pleurisy  as  its 
earliest  symptom,  frequently  will  simulate  abdominal  inflam- 
mation by  the  pain  referred  to  the  abdomen.  If  this  be  the 
case,  always  keep  in  mind  that,  with  a  careful  chest  examina- 
tion in  such  accidents,  fewer  cases  of  pleurisy  and  pneumonia 
will  be  mistakenly  submitted  to  abdominal  operations.  When 
one  is  sure  that  the  chest  is  in  normal  condition,  then  the 
abdomen  is  to  be  carefully  examined.  The  symptoms  and 
physical  signs  characteristic  of  perforation  are  sudden,  severe 
abdominal  pain,  with  local  tenderness  and  resistance.  If  these 
symptoms  persist,  and  if,  in  addition,  the  pulse  becomes  more 
rapid,  the  temperature  gradually  increases,  and  an  increase 
in  the  number  of  leucocytes  occurs,  there  is  sufficient  reason 
for  a  laparotomy,  and  a  surgeon  should  be  summoned  imme- 
diately. Indeed,  it  is  well  to  have  the  surgeon  see  the  case 
at  the  very  onset  of  such  an  alarming  symptom-complex.  In 
certain  instances  the  symptoms  and  physical  signs  are  so 
characteristic  that  a  positive  diagnosis  can  be  positively  made 
at  the  very  first  visit.  As  intimated  above,  one  must  care- 
fully differentiate  pain  due  to  flatulence  or  to  appendicitis 
from  this  condition,  because  an  operation  in  the  midst  of  a 
case  of  typhoid  fever  is  a  serious  matter,  but  delay  in  the 
operation  in  cases  of  perforation  is  fatal  to  the  well-being  of 
the  patient.  After  careful  examination  we  must  operate  if 
signs  warrant  it.  If  we  wait  until  abdominal  distention,  dis- 
appearance of  liver  dullness,  rapid  pulse  and  fall  of  tempera- 
ture are  present,  we  have  waited  too  long.  The  operation  has 
the  best  chance  of  curing  the  patient  if  done  in  the  first  few 
hours  after  the  appearance  of  symptoms.  Be  as  sure  of  the 
diagnosis  as  possible,  and  then  operate. 

A  routine  blood  examination  is  of  great  help  in  the  treat- 
ment of  typhoid  fever.  A  full  count  made  early  gives  data 
which  is  of  value.  This  count  should  be  repeated  every  week 
at  least,  and  every  day,  or  oftener,  in  certain  conditions.  The 
early  count  gives  us  a  guide  to  the  condition  of  the  blood. 


TYPHOID    FEVER.  19 

Any  increase  of  the  leucocytes,  or  decrease  of  the  hemoglobin 
and  erythrocytes,  will  then  be  interpreted  in  their  proper  way. 

Intestinal  Hemorrhage.  Hemorrhage  from  the  bowel  is 
difficult  to  treat,  for  the  reason  that  we  lack  means  of 
controlling-  the  bleeding.  Each  stool  should  be  carefully 
examined  by  the  nurse  in  charge  for  the  appearance  of  blood, 
and  if  blood  is  found,  either  in  large  or  in  small  quantities, 
all  food  should  be  stopped  at  once.  The  physician  should 
then  be  informed,  and  should  give  such  orders  as  seems 
proper  in  each  case.  All  bathing  and  sponging  should  cease. 
The  patient  should  not  be  told  that  he  has  had  a  hemorrhage. 
Physical  and  mental  rest  are  most  important.  If  there  is 
evidence  of  a  large  hemorrhage,  either  in  the  amount  of  blood 
passed  or  in  the  physical  signs,  a  hypodermic  of  }4,  grain 
(^0.008  Gm.)  of  morphin  should  at  once  be  ordered.  The 
foot  of  the  bed  should  be  raised  and  the  patient  left  strictly 
alone.  If  the  hemorrhage  is  repeated,  the  patient  should  be 
given  10  grains  (0.65  Gm.)  of  calcium  lactate  every  three 
hours,  or  a  pill  consisting  of  ^  grain  (0.032  Gm.)  of  acetate 
of  lead,  and  ^  grain  (0.032  Gm.)  of  powdered  opium  should 
be  given  every  three  hours,  care  being  taken  to  watch  for 
symptoms  indicating  the  general  effect  of  the  opium.  The 
patient  should  not  be  narcotized.  If  the  patient  develops 
hemorrhagic  tendencies,  hypodermic  injections  of  10  mils  (2.C6 
f.>)  of  normal  horse  serum,  repeated  every  three  hours,  should 
be  given  regularly.  If  there  is  much  failure  of  circulation,  the 
arms  and  legs  should  be  freely  bandaged,  beginning-  at  the 
hands  and  feet  respectively,  and  the  foot  of  the  bed  should 
be  raised.  If  practicable,  a  Crile  rubber  compression  appa- 
ratus should  be  used. 

The  question  as  to  whether  cardiac  stimulants  and  intra- 
venous injections  of  normal  salt  solution  shall  be  given  or 
withheld  is  always  a  very  difficult  one  to  solve. 

The  rapid  pulse  and  weakness,  with  a  tendency  to  faint- 
ness,  is  one  of  the  normal  results  of  the  large  hemorrhage. 
This  should  not  be  interfered  with,  unless  the  degree  of 
cardiac  failure  is  so  extensive  that  it  threatens  life.  To 
stimulate  the  circulation  with  drugs,  and  then  to  overfill  the 
vessels  with  normal  salt  solution  is  to  run  grave  risk  of  caus- 
ing a  repetition  of  the  hemorrhage  which  may  be  fatal.     Cer- 


20  SPECIFIC   INFECTIONS. 

tainly  elevation  of  the  foot  of  the  bed,  bandaging  and  mor- 
phin  must  be  tried  first. 

If  drugs  are  used,  hypodermics  of  strychnin,  cai^ein  and 
camphor  may  be  used.  Digitalis,  as  already  stated,  is  useless. 
Whisky,  brandy  or  champagne  may  be  tried  in  small  doses. 
Turpentine  appears  to  relieve  the  flatulence,  and,  perhaps,  is 
of  value  for  its  effect  upon  the  bleeding  surface.  Water  may 
be  given  by  the  mouth  if  the  patient  can  retain  this  better. 
Intravenous  injection  of  salt  solution  or  hypodermoclysis  may 
be  tried.  Not  more  than  a  pint  (480  mils)  of  liquid  should 
be  injected  by  either  method,  but  this  should  be  repeated  as 
necessity  demands. 

There  is  no  rule  which  will  cover  all  cases  as  to  when 
these  means  are  to  be  used,  but  each  case  must  be  judged  by 
itself.  This,  to  my  mind,  is  one  of  the  most  difficult  points 
upon  which  to  give  judgment.  During  the  first  twenty-four 
hours  albumin-water,  the  white  of  an  egg  dissolved  in  a  glass 
of  water,  may  be  given  every  three  hours.  This  will,  give 
adequate  nourishment,  and  if  it  be  sweetened  with  1  teaspoon- 
ful  (4  mils)  of  milk-sugar,  it  will  contain  more  nourishment, 
and  will  not  cause  any  irritation  of  the  bleeding  intestinal 
tract.  This  nourishment  may  be  given  for  forty-eight  hours. 
After  forty-eight  hours  with  no  return  of  bleeding,  food  may 
be  gradually  resumed,  first  liquids,  egg-water  reinforced  by 
milk,  then  peptonized  milk,  gradually  toast,  and  at  the  end 
of  five  or  six  days  the  food  which  was  being  taken  at  the 
beginning  of  the  hemorrhage. 

Acute  Dilatation  of  the  Stomach.  This  condition  is  not 
so  common  as  a  complication  of  typhoid  fever  as  it  is  of  some 
other  diseases,  such  as  pneumonia,  but  it  does  occur,  and 
should  be  recognized.  It  resembles  obstruction  of  the  bowels, 
comes  on  -suddenly,  with  signs  of  collapse  and  vomiting  of 
extremely  large  quantities  of  foul-smelling  material.  The 
greatly  enlarged  stomach  can  be  made  out  occupying  the 
entire  epigastrium,  and  even  the  upper  half  of  the  abdomen 
may  be  filled  by  this  greatly  distended  stomach. 

The  treatment  for  acute  gastric  dilatation  is  to  wash  out 
the  stomach  with  large  quantities  of  salt  solution,  to  elevate 
the  foot  of  the  bed,  and  to  place  the  patient  either  on  the 
right  side  or  on  the  face. 


TYPHOID    FEVER.  21 

Because  of  the  great  resemblance  of  this  condition  to 
intestinal  obstruction,  one  may  be  tempted  to  open  the 
abdomen.  This  is  fatal,  and  where  there  is  the  least  doubt 
in  the  mind  of  the  physician,  the  stomach  should  always  be 
emptied  by  a  stomach-tube,  as  a  means  of  certain  diagnosis. 

Laryngitis.  This  is  a  rather  frequent  complication  of 
typhoid  fever.  It  is  recognized  by  a  more  or  less  hoarse, 
unproductive  cough,  and  examination  of  the  larynx  shows  a 
reddened  mucous  membrane,  both  of  the  general  mucosa  and 
of  the  vocal  cords.  Its  treatment  consists  of  the  application 
of  cold  to  the  neck  in  the  form  of  ice-bags  or  cold  compresses, 
and  of  inhalation  of  steam. 

Bronchitis.  A  relatively  active  tracheobronchitis  is  pre- 
sent in  a  more  or  less  severe  grade  in  practically  all  cases  of 
typhoid  fever,  and,  if  severe,  and  especially  when  it  aiTects 
the  smaller  bronchi,  there  is  necessity  for  treatment.  If  there 
is  not  much  expectoration,  citrate  of  potassium  is  of  value. 
This  can  be  combined  with  ordinary  compound  licorice  mix- 
ture. This,  as  a  rule,  contains  enough  opium  to  control  the 
cough,  and  if  it  does  not,  paregoric  may  be  added  in  appro- 
priate doses.  If  the  patient  is  restless  and  nervous,  the  com- 
bination of  bromide  of  ammonia  and  bromide  of  potassium  is 
of  value.     Such  a  mixture  as  the  following  is  useful : 

IJ  Potassii  citratis 8  (123.4  gr.). 

Potassii  bromidi   16   (246.8  gr.). 

Misturse  glycyrrhizse  comp.  ..q.  s.  120   (4  f.§). 
M.     S. :    One  teaspoonful  (4  mils)  every  three  hours. 

Laryngeal  Perichondritis.  This  complication  is  rare,  but 
needs  immediate  treatment  when  it  occurs.  It  is  preceded 
first  by  hoarseness.  Examination  of  the  larynx  will  show  a 
redness  of  the  mucous  membrane.  As  the  condition  adA'ances, 
the  tissues  over  the  larynx  become  swollen,  edematous  and 
exquisitely  tender.  If  fluctuation  occurs,  the  abscess  may  be 
incised.  If  stridor  occurs  and  great  difficultv  in  breathing 
supervenes,  then  the  patient  may  develop  a  sudden  edema  of 
the  \zrynx.  Everything  must  be  kept  in  readiness  for  a 
tracheotomy,  so  that  this  simple  operation  may  be  done  at 
an  instant's  notice,  in  order  to  save  life. 

Periostitis  and  Ostitis.  These  complications  occur  late  in 
the  course  of  the  disease,  or  after  convalescence  has  set  in. 


22  SPECIFIC   INFECTIONS. 

Here  the  great  error  in  diagnosis  is  to  consider  the  painful 
swelling  as  due  to  rheumatism,  and  an  error  of  this  sort  may 
delay  proper  treatment  until  severe  lesions  occur,  which  may 
readily  be  fatal. 

Early  recognition  and  early  operation  are  of  the  greatest 
importance,  and  if  operation  is  done  early  there  will  be  little 
danger  of  a  serious  outcome. 

Pleurisy.  Pleurisy  is  recognized  by  a  sudden  pain  in  the 
chest,  aggravated  by  taking  a  deep  breath,  by  rapid,  painful 
breathing,  and  by  the  physical  signs  of  a  friction  rub.  If  the 
pain  is  extreme,  opium  should  be  used  and  the  chest  strapped. 
This  complication  is  frequently  the  forerunner  of  a  true 
pneumonia.  Occasionally  a  pleural  efifusion  contaminated  by 
typhoid  bacilli  develops,  as  in  the  rare  case  reported  by 
Pepper. 

Pneumonia.  This  complication  may  be  an  ordinary  acute 
croupous  pneumonia,  the  result  of  infection  by  the  pneumo- 
coccus.  It  is  occasionally  due  to  the  implantation  of  the 
typhoid  bacillus,  and  then  results  a  true  typhoid  pneu- 
monia. Its  symptoms  and  treatment  are  no  different  from 
the  treatment  of  pneumonia  under  ordinary  circumstances. 
The  routine  treatment  of  the  typhoid  fever,  not  excepting  the 
tub  baths,  need  not  be  interrupted.  Digitalis  here  may  be 
used  with  apparently  more  effect  than  when  the  heart  be- 
comes weak  simply  from  the  typhoid  poison  alone. 

Hypostatic  congestion  of  the  lungs  is  very  likely  to  occur 
in  the  more  severe  cases  of  typhoid  fever.  The  lungs  should 
be  daily  examined,  and  if  there  are  any  signs  of  congestion 
at  the  bases,  the  position  of  the  patient  should  be  changed 
constantly,  so  as  to  relieve  this  congestion.  Usually  caffein, 
strychnin  and  ammonia  are  necessary  under  these  conditions. 

Cardiac  Weakness.  Cardiac  weakness  is  the  result  of  the 
poison  of  the  disease.  It  is  due  to  the  effect  of  the  poison  on 
the  cardiac  muscle.  It  must  be  combated  by  the  general  tonic 
methods  as  described  under  general  treatment. 

Endocarditis  and  Pericarditis.  Both  endo-  and  pericardi- 
tis occur  as  the  result  of  infection  of  the  endocardium  and  the 
pericardium  by  the  typhoid  bacillus  They  can,  of  course, 
be  recognized  by  careful  examination  of  the  heart  itself. 
Extreme  quiet  is  necessary.    Application  of  cold  is  of  value. 


TYPHOID    FEVER.  23 

Digitalis  should  not  be  used  under  these  circumstances. 
It  causes  a  more  forcible  heart  action,  and  may  be  harmful. 

Phlebitis.  This  is  characterized  by  pain  and  tenderness 
along  the  line  of  a  superficial  vein.  Any  vein  may  become 
inflamed,  the  most  usual  one  afifected  being  the  left  external 
saphenous.  In  addition  to  the  pain  and  tenderness  along  the 
vein,  there  is  frequently  redness,  the  hardened  vein  can  be 
felt  to  roll  under  the  fingers,  and  there  is  also  edema  of  the 
foot  and  leg  on  the  afifected  side.  This  edema  first  appears 
about  the  inner  maleolus.  With  a  rise  of  temperature  and 
leucocytosis,  it  is  wise  to  examine  this  part  of  the  leg,  because 
often  this  is  the  first  point  to  show  disturbance.  The  whole 
leg,  from  foot  to  groin,  should  be  bandaged  lightly,  preferably 
with  a  gauze  bandage,  and  elevated  upon  pillows  so  that  the 
foot  should  be  slightly  higher  than  the  pelvis.  Applications 
of  a  saturated  solution  of  magnesium  sulphate  gives  relief  to 
the  pain,  which  is  more  or  less  severe.  This  is  more  cleanly 
than,  and  just  as  useful  as,  the  usual  use  of  ointments.  If 
the  pain  is  so  great  as  to  cause  much  distress  or  wakefulness, 
opium  in  some  form  can  be  used. 

Nephritis.  Albuminuria  with  a  few  tube-casts  is  a  con- 
stant accompaniment  of  practically  all  cases  of  typhoid  fever 
of  any  severity.  This  need  not  give  any  concern,  and  does 
not  call  for  any  special  treatment.  However,  frequent  exami- 
nations of  the  amount  and  character  of  the  urine  should  be 
made.  If  the  amount  decreases,  more  water  should  be  given 
in  order  to  increase  the  output. 

If  a  true  nephritis  occurs,  as  indicated  by  suppression  of 
the  urine  and  the  presence  of  blood,  blood-casts,  and  dark, 
granular  casts,  the  diet  must  be  restricted  to  the  most  bland 
articles,  and  water  in  large  quantities  is  to  be  given. 

Cystitis.  Is  an  occasional  complication,  and  is  best  treated 
by  the  use  of  hexamethylenamin. 

Delirium.  This  is  a  symptom  common  to  almost  all  cases 
of  typhoid  fever,  but  sometimes  it  needs  special  treatment. 
The  bromids  can  be  used  with  benefit,  cold  to  the  head  is  of 
value,  and  merely  the  voice  of  the  nurse,  calming  words,  or 
the  stroke  of  a  hand  will  occasionally  do  much  to  quiet  the 
delirious  patient.  Morphin  hypodermically,  alone  or  com- 
bined with  hyoscin  or  scopolamin,  ^yill  spipetimes  be  neces-» 


24  '  SPECIFIC    INFECTIONS. 

sary  to  give  the  patient  rest.  The  low,  muttering  delirium, 
with  picking  at  the  bed-clothing,  like  the  ordinary  delirium 
of  the  disease,  is  an  indication  of  the  toxemia.  It  is  best 
combated  by  elimination,  which  can  be  obtained  from  the 
ingestion  of  water,  either  by  the  mouth  or  administered 
through  hypodermyolysis  or  by  intravenous  injection  of  nor- 
mal salt  solution.  Actual  insanity  occurs  sometimes  as  a 
post-febrile  condition.  This  is  doubtless  toxic  and  is  due  to 
the  weak  condition  of  the  patient  causing  a  cerebral  disturb- 
ance. It  is  best  combated  by  increasing  the  nourishment  of 
the  patient.  If  the  delirium  is  extremely  wild,  then  the  use 
of  bromids,  and,  if  necessary,  opium  is  indicated. 

Physical  restraint  by  means  of  restraining  sheets,  a  simple 
sheet  folded  into  a  strip  12  or  18  inches  (30.4  or  45.7  cm.)  in 
breadth,  passed  over  the  chest,  and  fastened  to  the  bed  rails,  is 
helpful.  The  patient  may  be  allowed  to  move  his  hands  and  feet, 
but  the  pull  of  the  sheet  over  the  chest  often  causes  the  patient  to 
cease  his  efforts  of  attempting  to  get  up.  Cuffs,  restraining 
straps  to  restrain  the  legs  and  arms,  and  a  regular  strait- 
jacket  should  not  be  used.  It  is  better  that  the  patient  be 
quieted  by  some  narcotic  than  allowed  to  exhaust  himself 
with  the  physical  exertion  he  exerts  when  subjected  to 
mechanical  restraints  of  this  sort. 

Meningitis.  This  is  a  rare  complication,  but  occasionally 
demands  attention.  Meningisimus,  however,  occurs,  which  in 
many  ways  resembles  a  true  meningitis,  and  both  meningitis 
and  meningisimus  are  treated  well  by  spinal  puncture.  This 
can  be  repeated  every  twenty-four  or  forty-eight  hours  with 
nothing  but  good  results.  Bromids  may  be  used,  also  hyo- 
scin.  Morphin,  for  some  reason,  apparently  precipitates  a 
coma  in  certain  cases;  it  should  be  used  with  caution,  in  small 
doses,  and  better  in  combination  with  hyoscin  than  alone. 

Furunculosis.  This  is  a  post-febrile  complication,  and 
gives  rise  to  a  low  grade  of  fever  and  decided  emaciation. 
Early  evacuation  of  the  pus  is  important.  An  autogenous 
vaccine,  made  from  a  culture  of  the  contents  of  the  furuncle, 
is  often  of  the  greatest  value. 

Cholecystitis.  Frequently  the  gall-bladder  becomes  in- 
flamed during  an  attack  of  typhoid  fever,  giving  rise  to  pain, 
tenderness,  and  resistance  in  the  region  of  that  organ,     The 


TYPHOID    FEVER.  25 

symptoms  of  this  local  condition  are  increased  fever  and 
leucocytosis.  The  situation  of  the  pain  over  the  gall-bladder 
itself  allows  a  probable  differentiation  between  this  condition 
and  appendicitis.  The  treatment  of  cholecystitis  in  all  but 
rare  cases  is  one  of  watchfulness  and  treatment  of  the  symp- 
toms— cold  compresses  or  an  ice-bag  over  the  inflamed  gall- 
bladder, with  perfect  rest  and  the  administration  of  hexa- 
methylenamin  are  the  best'  methods  to  pursue  in  the  vast 
majority  of  cases.  Occasionally,  however,  there  are  cases  in 
which  the  inflammation  goes  on  to  suppuration,  and  we  are 
confronted  with  a  condition  of  much  danger,  suppurative 
cholecystitis.  If  the  fever  becomes  intermittent,  if  the  leuco- 
cytes rise  rapidly,  and  if  a  mass  appears  over  the  gall-bladder, 
it  is  best  to  call  a  careful,  conservative  surgeon  in  consulta- 
tion. A  laparotomy  should  certainly  be  performed  if  one  is 
satisfied  as  to  the  existence  of  suppuration. 

Appendicitis.  The  appendix  is  frequently  the  seat  of 
inflammation  during  typhoid  fever,  but  usually  the  process  is 
simple  in  type ;  the  condition  is  not  of  very  grave  moment, 
and  disappears  with  the  subsidence  of  the  typhoid  infection. 
Occasionally,  however,  a  typhoid  ulcer  invades  the  appendix, 
and  may  give  rise  to  perforation.  Also,  occasionally  the 
appendix  becomes  very  acutely  inflamed,  and  ulcerative  or 
suppurative  appendicitis  is  present.  These  latter  conditions 
can  be  diagnosed  by  increasing  circumscribed  tenderness  and 
resistance  of  the  belly,  and  by  increasing  leucocytosis  with 
fever  and  distress  of  the  patient.  When  appendicitis  occurs 
as  a  complication  of  typhoid,  the  same  rule  prevailing  when 
it  appears  in  a  patient  in  good  health  cannot  be  safely 
observed.  In  health  an  operation  should  be  done  at  the 
earliest  moment,  but  the  dangers  of  an  operation  dur- 
ing the  course  of  typhoid  fever  are  greater  than  the 
danger  of  waiting  in  the  usual  case.  The  mild  cases  must 
be  treated  symptomatically  with  cold,  starvation  and  opium 
to  relieve  the  pain.  If,  however,  the  case  goes  on  to  sup- 
puration, an  operation  must  be  done  at  the  earliest  possible 
moment. 

The  rule  to  follow,  then,  is  to  operate  when  the  danger 
from  the  local  appendicitis  appears  greater  than  tlie  danger 
from  an  operation.    In  health,  I  repeat,  given  a  good  surgeon, 


26  SPECIFIC   INFECTIONS. 

the  dangers  of  an  operation  are  nil  as  compared  with  the 
potential  dangers  of  an  appendicular  inflammation. 

Convalescence.  The  patient's  convalescence  will  be  shorter 
if  the  food  has  been  kept  up  to  the  maximum  in  amount  dur- 
ing the  stage  of  active  fever.  As  a  rule,  one  week  after  a 
patient  is  free  from  fever  night  and  morning,  he  can  be 
allowed  to  sit  up  in  bed.  In  two  weeks  he  can  be  out  of  bed 
and  walk  about.  Care  not  to  overload  the  stomach  with  food 
is  one  of  the  most  necessary  rules  of  convalescence.  Let  the 
food  be  mixed,  of  almost  any  reasonable  kind,  but  it  must 
be  moderate  in  quantity. 

Exercise  must  be  very  gradually  undertaken,  the  first  act 
sitting  up  in  bed,  next  in  a  chair  beside  the  bed,  then  short 
walks,  and  at  the  end  of  two  weeks,  walks  which  will  be  of 
considerable  length. 

Typhoid  spine,  which  is  probably  a  periarthritis,  often 
gives  rise  to  an  extreme  amount  of  pain  and  a  semi-invalidism 
for  a  long  series  of  weeks.  Massage,  occasionally  strapping, 
and  sometimes  a  light  steel  brace  are  a  help.  The  use  of 
potassium  iodid  is  of  value. 

Use  of  Vaccines.  The  prophylactic  use  of  vaccines  in 
typhoid  fever  has  been  abundantly  proven,  as  shown  by  their 
employment  in  the  American  army  and  in  the  armies  of 
Europe  now  at  war.  The  method  of  use  employed  in  America 
is  to  use  the  bodies  of  t3^phoid  bacilli  killed  at  53°  C.  (127.4° 
F.)  ;  500,000,000  of  these  are  injected  hypodermically ;  in  a 
period  of  ten  days  100,000,000  are  injected,  as  the  initial  dose, 
and  ten  days  later  another  100,000,000.  Frequently  there  is  a 
local  induration  which  is  red,  swollen  and  edematous.  Occa- 
sionally there  is  a  feeling  of  malaise  with  rise  of  temperature 
after  each  injection,  but  usually  the  post-vaccinal  reaction  is 
so  mild  that  the  patient  does  not  have  to  keep  his  bed.  Infre- 
quently the  reaction  is  more  severe,  and  the  temperature  rises 
as  high  as  102^^°  F.  (39°  C),  and  in  such  cases  the  patient 
is  likely  to  be  indisposed  for  several  days. 

The  therapeutic  use  of  vaccines  is  still  on  trial.  Many 
reports  are  published  appearing  to  prove  that  cases  treated 
with  vaccines  of  the  typhoid  bacillus  do  well,  but,  on  the  con- 
trary, other  reports  throw  doubt  on  the  actual  value  of  this 
method  of  treatment,     On  the  whole,  the  effect  induced  by 


CROUPOUS    PNEUMONIA.  27 

the  foreign  protein  may  be  more  deleterious  than  that  of  the 
disease  it  is  meant  to  combat.  Apparently  there  are  no  bad 
results  reported.  In  this  connection  several  articles  recently 
published  would  indicate  that  any  foreign  protein  has  an. 
effect  on  the  cases  of  typhoid  fever  in  which  they  have  been 
used  intravenously  similar  to  the  effect  of  the  specific  typhoid 
vaccine. 

PARATYPHOID   FEVER. 

This  disease  closely  resembles  infection  by  the  true 
lyphoid  bacillus.  Indeed,  the  paratyphoid  bacillus  a  and  the 
paratyphoid  bacillus  h  are  but  varieties  of  the  typhoid  bacil- 
lus. The  disease  can  be  distinguished  from  true  typhoid  by 
the  fact  that  the  blood-serum  of  the  patient  will  not  aggluti- 
nate typhoid  bacilli,  but  will  agglutinate  either  the  paraty- 
phoid a  or  b  bacteria.  The  actual  specific  diagnosis,  however, 
can  be  made  by  blood-cultures,  or  cultures  from  the  stool  or 
urine. 

The  symptoms  of  paratyphoid  are  essentially  those  of 
typhoid  fever. 

The  diagnosis,  prophylaxis  and  treatment  differ  in  no  way 
from  that  of  typhoid  fever.  The  reader  is  referred  for  details 
to  the  article  on  the  treatment  of  typhoid  fever  (page  7). 

CROUPOUS    PNEUMONIA. 

Croupous  pneumonia,  or  lobar  pneumonia,  is  due  to  infec- 
tion by  the  pneumococcus,  a  micro-organism  usually  found  in 
the  mouth  and  in  the  air-passages  of  healthy  persons,  and 
prone  to  become  virulent  under  certain  circumstances.  The 
exact  reason  why  these  organisms  are  virulent  under  certain 
conditions  and  not  under  other,  and  even  similar  ones,  is  not 
known.  The  symptoms  present  in  the  usual  case  of  pneu- 
monia are  an  initial  chill  of  more  or  less  severity;  fever,  the 
temperature  rising  rapidly  to  103°  or  104°  F.  (39.4°  or  40° 
C),  with  dyspnea  and  pain  in  the  chest,  aggravated  by  tak- 
ing a  long  breath.  The  degree  and  continuance  of  the  pain 
depends  upon  the  extent  of  the  pleuritic  lesion  incident  to  the 
individual  case.  As  the  case  progresses,  the  symptoms  vary 
with  the   degree  of  pulmonary   consolidation   and   with   the 


2B  SPECIFIC   INFECTIONS. 

degree  of  toxicity  in  the  case  in  question.  Occasionally  the 
patient  is  extremely  ill,  with  high  fever,  rapid  cardiac  action, 
delirium,  and  every  evidence  of  extreme  toxicity,  while  the 
amount  of  pulmonary  implication  is  comparatively  small.  In 
such  instances  there  is  a  true  pneumococcemia. 

On  the  other  hand,  the  size  of  the  pneumonic  area  may  be 
very  great,  the  dyspnea  and  cyanosis  extreme  on  account  of 
the  extensive  solidification,  and  yet  the  subject  shows  but 
moderate  toxemia. 

The  disease  is,  however,  a  true  pneumococcemia,  as  proved 
by  the  fact  that  the  micro-organisms  have  been  found  in  the 
blood-stream,  and  also  by  the  fact  that  organs  other  than  the 
lungs  become  inflamed  by  the  local  inflammation  excited  by 
the  pneumococcus,  for  instance,  in  the  brain  and  spinal  cord. 

The  physical  signs  of  the  condition  consist  of  dullness 
over  the  affected  area  of  the  lung;  at  first  distant  breathing 
with  crepitant  rales ;  and  within  twenty-four  hours,  depending 
largely  upon  the  resistance  of  the  patient  and  upon  the  degree 
of  infection,  in  the  usual  case,  bronchial  breathing.  The 
degree  of  further  progress  varies,  usually  one  single  lobe  is 
pneumonic,  and  this  is  followed  by  invasion  usually  of  an 
adjoining  lobe.  There  is  practically  always  a  pleurisy  sur- 
rounding the  lobe  affected.  This  may,  or  may  not,  give  rise 
to  an  exudate,  which  either  remains  serous  or  becomes  pur- 
ulent. Death  usually  occurs  as  the  result  of  failure  of  the 
circulation,  which  may  be  in  turn  due  either  to  the  existing 
septicemia  or  to  dilatation  of  the  right  heart,  the  result  of  the 
pulmonary  process. 

The  problem  of  treatment,  then,  is,  first,  the  use  of  specific 
sera  or  specific  drugs;  and,  second,  the  use  of  other  than 
specific  measures. 

SPECIFIC  TREATMENT. 

When  sera  were  first  used  as  a  treatment  for  bacterial  dis- 
eases, and  when  diphtheria  and  tetanus  came  under  the  ban 
of  the  antitoxic  sera,  it  was  hoped,  and,  indeed,  expected  that 
the  pneumococcus  would  give  as  efficient  a  serum  as  the 
diphtheria  and  tetanus  bacilli  yielded.  Until  recently  this 
hope  has  not  been  fulfilled.  The  mortality  in  a  large  number 
of  cases  of  pneumonia  treated   by   antipneumococcic  serum 


CROUPOUS    PNEUMONIA.  29 

was  no  lower  than  that  of  those  treated  by  ordinary  expectant 
means.  Within  the  last  three  years,  however,  Cole,  of  the 
Rockefeller  Institute,  has  put  the  specific  treatment  of  pneu- 
monia upon  what  appears  to  be  a  firm  basis.  As  yet,  unfor- 
tunately, the  methods  proposed  are  too  cumbersome  to  make 
the  method  practicable  for  the  use  of  anyone  who  has  not 
access  to  a  well-equipped  hospital,  and  to  a  laboratory  in 
which  the  proper  bacteriologic  examinations  can  be  made. 
Philadelphia,  through  the  Board  of  Health,  now  gives  oppor- 
tunity to  physicians  to  use  this  serum. 

Cole  in  two  addresses,  one  before  the  State  Medical 
Society  of  Pennsylvania,  and  the  other  before  the  Congress 
of  American  Physicians  and  Surgeons  in  Washington,  makes 
statements  about  the  specific  treatment  of  pneumonia,  of 
which  the  following  is  an  abstract: 

In  the  first  place,  pneumonia,  as  recognized  by  the  clini- 
cian, is  not  the  result  of  an  infection  due  to  identical  micro- 
organisms. It  has  been  discovered  that  pneumococci  can  be 
divided  into  groups,  the  characteristics  of  the  members  of  one 
group  dififering  widely  from  the  peculiarities  of  those  of  the 
other  groups,  and  then,  again,  that  about  5  per  cent,  of  the 
cases  diagnosed  as  pneumonia  are  due  to  infections  by  other 
germs,  such  as  the  staphylococcus,  the  streptococcus  and 
Friedlander's  bacillus. 

In  order  to  identify  the  various  groups  of  pneumococci, 
the  following  method  is  used :  A  small  portion  of  the  sputum 
coughed  up  from  the  lung  is  injected  into  the  peritoneal 
cavity  of  a  mouse.  After  the  micro-organisms  have  devel- 
oped, the  peritoneal  cavity  is  washed  out  with  salt  solution, 
and  the  washing  is  then  centrifugalized  for  a  short  time  to 
remove  leucocytes  and  other  animal  cells.  To  a  small  portion 
of  this  suspension,  immune  sera  of  types  1  and  2  are  added. 
If  agglutination  occurs  in  either  mixture,  we  know  that  we 
are  dealing  with  a  type  of  micro-organism  corresponding  to  that 
particular  serum.  If  no  agglutination  occurs,  the  bacteria  are 
types  3  or  4.  Type  3  bacteria  can  usually  be  detected  by 
direct  examination  of  the  peritoneal  exudate.  The  micro- 
organism possesses  larger  capsules  than  the  others,  and  m 
animals  produces  a  very  stiff  mucous  exudate.  Then  there 
are  a  number  of  germs  which  do  not  fall  intO  any  of  these 


^30  SPECIFIC   INFECTIONS. 

groups,  but  differ  among  themselves.  This  group  has  been 
called  type  4.  It  is,  therefore,  seen  that  pneumococci  can  be 
grouped  into  four  types,  of  which  both  types  1  and  2  produce 
in  animals  a  protective  serum,  while  types  3  and  4  do  not  pro- 
duce protective  serum.  The  immune  serum  of  types  1  and  2 
has  been  obtained  from  horses.  Its  method  of  production 
is  that  commonly  employed  in  producing  other  therapeutic 
sera.  Type  1  serum  has  a  very  great  strength.  The  serum 
obtained  against  type  2  is  of  less  potency.  Very  recently  the 
New  York  Board  of  Health  has  been  able  to  produce  a  serum 
against  type  3  which,  while  it  is  of  no  value  as  a  curative 
agent,  shows  that  it  may  be  possible  hereafter  to  produce  a 
serum  valuable  in  infection  from  this  particular  micro-organism. 
The  reason  that  sera,  which  heretofore  have  been  employed 
as  a  curative  agent,  have  been  ineffective,  is  because  the  sera 
have  not  been  produced  with  a  knowledge  that  these  various 
types  of  pneumococci  produce  sera  which  are  curative  only 
against  germs  of  their  own  type. 

After  the  observation  of  432  cases  of  pneumonia  at  the 
Rockefeller  Hospital  and  at  the  Pennsylvania  Hospital,  in 
Philadelphia,  it  has  been  discovered  that  approximately  one- 
third  of  the  cases  of  pneumonia  are  due  to  infections  of  type 
1,  one-third  to  infections  of  type  2,  and  the  other  third  to 
infection  of  types  3  and  4.  The  mortality  of  the  cases  infected 
by  type  1  and  not  treated  by  immune  sera  is  about  25  per 
cent. ;  those  of  type  2  about  29  per  cent. ;  those  of  type  3,  45 
per  cent.,  and  those  of  type  4,  12  per  cent. 

The  results  of  the  treatment  with  type  1  serum  are  encour- 
aging. The  number  so  treated  is  not  large,  72  cases,  treated 
by  type  1  serum,  with  6  deaths,  a  mortality  of  8  per  cent. 
This  is  a  distinct  gain  over  the  mortality  of  25  per  cent,  when 
not  treated  with  serum. 

The  method  of  treatment  is  as  follows :  As  soon  as  a 
pneumonia  patient  is  admitted  to  the  hospital  a  yz  mil  (8  m.) 
of  serum  is  given,  in  order  to  test  the  sensitiveness  of  the 
patient  and  to  desensitize  the  subject  if  possible.  Then  when 
the  type  of  bacteria  is  discovered,  80  mils  (2.6  f^)  of 
serum,  are  injected  into  the  vein  of  the  individual,  and  this 
procedure  is  repeated  every  twelve  hours  until  the  tempera- 
ture  and   pulse   rate   fall.      Following  the   injection    a   more 


CROUPOUS  PNEUMONIA.  31 

or  less  severe  reaction  is  set  up,  as  evidenced  by  rapid  pulse, 
high  temperature,  and  frequently  a  chill.  These  reactions, 
however,  in  the  Rockefeller  cases  have  not  been  severe. 
A  large  number  of  patients  receiving  this  serum  suffered  from 
serum  sickness  after  a  week  or  ten  days.  These  symptoms 
are  distressing,  but  not  dangerous,  and  in  more  than  100  cases 
treated  at  the  Rockefeller  Institute  there  were  no  serious 
results. 

When  it  is  impracticable  to  delay  the  administration  of  a 
specific  serum  until  the  type  of  pneumococcus  is  determined, 
one  feels  warranted  in  using  one  of  the  "stock"  polyvalent 
serums,  now  obtainable  in  the  open  market.  Such  a  serum, 
which  contains,  in  rational  proportions,  the  antibodies  against 
the  several  types  of  infecting  pneumococci,  should  be  given 
intravenously  in  doses  of  from  100  to  200  mils  (3.38  to  6.76  f5), 
and  the  injection  repeated  in  from  eight  to  twelve  hours, 
according  to  the  needs  of  the  individual  case.  In  pneumonias 
Complicated  by  a  Streptococcus  hemolyticus  infection  the  use 
of  the  appropriate  antistreptococcus  serum  is  urgently  in- 
dicated. 

A  second  form  of  specific  treatment  is  by  the  use  of  chemi- 
cals. Several  years  ago  Morganroth  undertook  to  study  the 
action  of  quinin  on  pneumonia,  and  also  investigated  the 
effects  exerted  in  the  injection  by  a  number  of  derivatives  of 
the  drug.  He  found  that  quinin  is  a  specific  bactericide  against 
the  pneumococcus,  but  that  its  action  in  this  direction  is 
very  slight.  He  found,  furthermore,  that  one  of  the  cinchona 
derivatives,  know'n  as  ethylhydrocuprein,  possesses  a  bac- 
tericidal action  against  pneumococci  in  a  very  high  degree, 
but,  unfortunately,  it  is  also  a  very  toxic  drug,  and  there  is 
a  close  correspondence  between  the  curative  and  the  lethal 
doses,  so  that  as  yet  it  is  scarcely  a  proper  drug  to  use 
promiscuously.  Another  particular  action  of  this  derivative 
of  quinin  is  that  it  makes  the  micro-organisms  acquire  a 
so-called  fast  quality,  owing  to  which  they  become  entirely 
resistant  to  the  action  of  the  drug,  and  are  not  affected 
thereby. 

It  is  to  be  hoped  that  before  a  great  time  has  passed  a 
serum  made  under  the  Rockefeller  rules  will  be  put  upon  the 
market,  and  will  be  used  freely  by  practising  physicians,  so 


32  SPECIFIC  INFECTIONS. 

that   at   least  one   form   of  the  disease   may   have   an   actual 
specific  cure  for  it. 

TREATMENT  BY  OTHER  THAN  SPECIFIC 
METHODS. 

Six  essentials  of  treatment  stand  out  as  applicable  to 
practically  every  case  of  pneumonia,  aside  from  which  there 
are  many  other  helpful  details  to  be  carried  out : 

1.  Early  recognition  of  the  case. 

2.  Absolute  rest. 

3.  Abundance  of  fresh  air. 

4.  Proper  amount  of  good  food. 

5.  Constant  watchfulness. 

6.  Administration  of  proper  drugs  at  proper  times. 

Rest.  Mental  as  well  as  physical  rest  must  be  absolute, 
and  all  unnecessary  movement  must  be  interdicted  by  the 
physician.  The  patient  should  not  rise  for  urination  or 
defecation,  to  which  end  a  bed-pan  must  be  used.  Visitors 
in  the  sick-room  should  be  distinctly  limited,  and,  it  is  better, 
if  the  patient  does  not  become  restless  under  the  restriction, 
to  allow  no  visitors  at  all.  On  the  other  hand,  if  the  presence 
of  the  wife  or  husband,  or  any  other  person  soothes  the 
patient,  it  will  be  best  for  that  individual  to  be  admitted  to 
the  sick-room.  But  care  must  be  taken  that  the  patient's 
room  is  not  made  a  visiting  place  for  all  friends  and  relatives. 
In  hospital  wards  where  visiting  is  not  controlled  as  carefully 
as  in  private  homes,  I  think  it  is  quite  certain  that  patients 
affected  with  pneumonia,  and,  indeed,  with  any  other  serious 
condition,  are  not  quite  so  well  after  visits  have  been  made. 
The  rest  should  continue  several  days  after  convalescence  has 
begun.  One  must  remember  that  the  majority  of  uncompli- 
cated croupous  pneumonia  cases  get  well  after  a  sudden  crisis, 
and  that  the  remainder  recover  after  a  lysis  of  three  or  four 
days'  duration. 

For  a  week  or  ten  days  the  patient  has  been  extremely  ill, 
and  all  his  forces  are  weakened.  Therefore,  extreme  care 
must  be  taken  to  avoid  any  unnecessary  strain  for  several 
days.  After  the  temperature  has  remained  normal  about  one 
week,  provided  that  the  patient  seems  well  otherwise,  he  may 
be  allowed  to  sit  up,  at  first  with  a  back-rest,  in  bed,  and 
later  in  an  easy  chair. 


CROUPOUS    PNEUMONIA.  33 

Fresh  Air.  This  means  pure,  unheated,  unbreathed  air, 
admitted  into  the  room  through  wide-open  windows.  A  room 
with  two  windows  opposite  each  other  is  best,  so  that  a  cross 
draft  may  be  formed,  thus  keeping  the  air  in  the  room  con- 
stantly changed.  The  patient  need  not  be  placed  in  the  draft, 
although,  except  for  discomfort,  it  is  a  matter  of  indifference 
whether  a  draft  blows  over  the  sick  one,  provided  that  he  be 
well  protected  with  clothing  so  that  the  body  will  not  be 
chilled.  If  it  is  practicable,  it  is  still  better  for  the  patient 
to  be  on  an  open  porch,  protected  so  that  the  wind  and  storm 
will  not  drive  over  his  body.  To  the  writer's  mind  the 
direction  to  keep  the  temperature  of  the  room  between  60° 
and  70°  F.  (15.5°  and  21.1°  C.)  is  a  mistake.  The  tempera- 
ture of  the  air  in  the  room  should  be  that  of  the  outside  air; 
in  cold  weather  the  patient  should  have  blankets  both  over 
him  and  under  him,  and  be  clothed  in  a  cap  and  warm,  loose 
underclothing,  opened  at  the  back  to  facilitate  easy  removal. 
Thick  mittens  on  the  hands  are  comforting,  if  the  patient 
desires  to  have  his  hands  outside  the  bed-covers.  The  nurse 
should  be  warmly  clad  with  a  soft,  thick  sweater;  her  feet 
should  be  protected  with  proper  shoes,  and  her  legs  and 
ankles  with  warm  underclothing.  If  the  patient's  bed-cloth- 
ing has  to  be  changed,  or  if  the  body  has  to  be  exposed,  then, 
of  course,  the  windows  in  the  room  must  be  closed,  and,  if 
practicable,  heat  turned  on  in  the  room.  It  is  proper  to  have 
one  of  two  arrangements :  either  the  patient  should  be  treated 
on  a  porch  connecting-  with  a  room  into  which  the  bed  can  be 
rolled  w^hen  changes  are  necessary,  or  two  adjoining  rooms 
should  be  used,  the  one  in  which  the  patient  remains  with  the 
windows  wide  open  as  directed,  the  other  to  be  kept  warm 
for  changing  the  patient's  clothing.  The  time  which  the 
patient  will  spend  in  the  protected  room  will  depend  largely 
upon  the  patient  himself.  Time  and  again  one  who  has  been 
out  on  the  porch  or  in  an  open  room  with  the  temperature  far 
below  freezing,  when  brought  into  the  warmer  room,  which 
has  been  closed  for  the  purpose  of  changing-  the  patient,  will 
make  the  request  to  be  put  into  the  open  room,  or  on  the 
porch  as  soon  as  possible. 

If  inquiry  is  made  of  the  patients  they  will  almost  without 
exception  declare  themselves  more  comfortable   in  the   open 

3 


34  SPECIFIC   INFECTIONS. 

porch  or  room.  While  it  has  seemed  that  pneumonia  subjects 
do  better  in  open  cold  rooms  than  when  the  weather  is  warm, 
it  is  not  so  much  the  temperature  as  it  is  the  fresh  air  which 
is  beneficial. 

If  a  patient  is  put  into  a  cold  room,  or  on  a  cold  porch, 
and  kept  there  without  free  circulation  of  air,  he  will  suffer 
about  as  much  as  if  he  were  in  a  closed  warm  room.  Open 
the  windows,  and  at  once  the  patient  will  be  more  comfort- 
able, whether  the  air  be  cold  or  warm.  This  rule  of  keeping 
the  air  fresh  and  in  full  circulation  holds  whether  it  is  clear 
and  dry  or  rainy  and  wet.  Protect  the  room  and  the  bed  from 
the  storm  by  means  of  screens,  but  allow  free  circulation  of 
the  air. 

These  opinions  may  seem  too  radical,  especially  as  to  the 
opinions  expressed  regarding  the  cold  and  drafts.  It  is  based 
upon  the  observation  of  many  cases  in  hospital  and  private 
practice,  and  there  can  be  no  question  as  to  the  good  results 
coming  from  the  fresh  air.  Protect  the  patient,  and  neither 
cold,  drafts,  nor  dampness  will  harm  him. 

Food.  The  food  necessary  to  a  pneumonia  patient  should 
be  nourishing,  and  of  not  too  great  quantity.  It  should  be 
of  a  character  which  will  not  undergo  fermentation  in  the 
intestines  any  more  than  is  possible.  The  bowels  should  be 
regularly  moved,  so  as  to  prevent  the  collection  of  fecal 
material,  and  consequent  intestinal  distention. 

Food  should  be  stopped  or  reduced  to  a  minimum  when 
abdominal  distention  becomes  serious. 

Constant  Watchfulness.  A  trained  nurse  constantly  in 
attendance  is  just  as  necessary  in  pneumonia  as  it  is  in 
typhoid  fever.  A  sudden  delirium  or  a  rapidly  occurring 
cardiac  failure  may  not  be  observed  if  no  one  is  in  attend- 
ance who  knows  how  to  interpret  symptoms. 

The  physician  should  either  see  the  patient  twice  a  day 
or  should  be  in  position  to  hear  from  a  trained  nurse  frequent 
reports  of  progress  during  the  day  and  night. 

TREATMENT   OF   SPECIAL   SYMPTOMS. 

Fever.  The  temperature  in  croupous  pneumonia  ordi- 
narily ranges  between  103°  and  105°  F.  (39.4°  and  40.5°  C). 
For  eight  or  nine  days  this  degree  of  temperature  is  not  par- 


CROUPOUS    PNEUMONIA.  35 

ticularly  harmful.  Baths  and  sponges  are  not  necessary,  and 
it  would  seem  that  the  high  temperature  for  that  length  of 
time  is  no  more  harmful  than  the  disturbance  which  their 
administration  entails.  Cold  may  be  applied  to  the  head  or  to 
the  affected  side  of  the  chest  so  as  to  control  the  temperature 
to  a  certain  extent.    Coal-tar  antipyretics  should  never  be  used. 

Delirium.  The  delirium  of  pneumonia  can  be  relieved  by 
methods  designed  to  combat  the  toxemia,  to  wit,  abundance 
of  fresh  air  and  an  abundance  of  liquid.  Bromid  of  potas- 
sium in  doses  of  20  grains  (1.3  Cms.)  every  two  or  three 
hours  is  of  great  value.  When  the  delirium  occurs  in  a 
patient  addicted  to  the  use  of  alcohol,  I  am  quite  sure  that 
the  use  of  alcohol  in  moderately  large  doses  will  quiet  the 
patient  as  will  no  other  drug. 

When  the  patient  is  violently  delirious,  thrashing  about 
the  bed  without  sleep,  wearing  himself  out,  the  use  of  mor- 
phine hypodermically,  either  alone  or  combined  with  hyoscin, 
is  of  the  greatest  amount  of  value.  The  patient  should  not 
be  restrained  by  means  of  a  strait-jacket  or  straps,  except 
under  dire  necessity.  The  writer  has  seen  patients  so 
exhausted  when  having  to  fight  against  the  straps,  that 
exhaustion  leading  to  death  has  seemed  to  be  the  result  of 
the  uncontrolled  restlessness.  Better  by  great  odds  the  quiet- 
ing effect  of  moderate  doses  of  opium  than  the  forcible 
restraint  of  the  strait-jacket. 

Circulatory  Disturbances.  The  circulation  in  pneumonia 
is  affected  apparently  in  several  ways.  First,  by  the  bac- 
teremia, in  which  the  patient  is  poisoned  by  the  bacterial  toxin 
circulating  in  the  blood.  In  this  condition  the  heart  is  rapid 
and  feeble,  the  first  sound  is  weak,  and  the  blood-pressure  is 
frequently  low.  In  regard  to  the  height  of  the  blood-pressure 
and  the  prognosis  of  the  case,  a  low  pressure  is  significant  of 
a  severe  toxic  state.  Although  occurring  just  at  the  height 
of  the  sepsis  and  when  death  is  imminent,  there  is  rising 
blood-pressure. 

The  circulation  is  also  affected  when  there  is  extensive 
pulmonary  infiltration,  when  the  pulmonary  circulation  is 
embarrassed,  and  when  there  is  much  cyanosis.  In  these 
conditions  there  is  frequently  high  blood-pressure. 


36  SPECIFIC   INFECTIONS. 

In  the  cases  with  sudden  circulatory  failure,  with  decided 
cyanosis,  leaking  skin,  and  running,  feeble  pulse,  there  is 
apparently  failure  of  the  vasomotor  system,  and  the  patient 
is  virtually  in  a  state  of  shock. 

Each  of  the  conditions  of  the  circulation  needs  a  different 
treatment. 

In  the  first,  with  high  and  often  irregular  fever,  possibly 
with  a  low  leucocytic  count  and  low  muttering  delirium, 
fresh  air,  cold  sponges,  normal  salt  solution  either  by  hypo- 
dermoclysis  or  intravenous  injection,  or  protoclysis,  are  valu- 
able. Caffein  in  the  form  of  cafifein  sodium  benzoate,  used 
hypodermically,  and  strychnin  are  valuable.  Digitalis  should 
be  used,  but  its  value  is  much  more  problematic. 

In  the  second  condition,  with  dilatation  of  the  right  side 
of  the  heart  and  a  high  blood-pressure,  cyanosis  and  accen- 
tuation of  the  second  pulmonic  sound,  blood-letting  is  of  the 
greatest  amount  of  value.  Here,  the  use  of  digitalis  is  indi- 
cated. Other  cardiac  stimulants,  such  as  caffein  and  ammonia, 
also  can  be  called  into  use  here. 

The  third  condition,  with  sudden  fall  of  blood-prssure, 
running  pulse  and  leaking  skin  is  the  most  hopeless  of  all, 
and  here  strychnin,  cafifein,  the  intravenous  injection  of 
adrenalin  chlorid  may  be  tried.  In  the  author's  experience, 
however,  all  such  measures  are  of  little  real  value.  The  pres- 
sure will  rapidly  rise,  but  the  hypertension  is  of  extremely 
short  duration.  Strophanthin  and  digitalis  must  be  used 
hypodermically  with  the  hope  of  strengthening  the  failing 
heart-muscle.  Atropin  in  full  doses  should  be  used  to  over- 
come the  cedema  of  the  lungs. 

Oxygen  may  be  used,  and  will  give  some  comfort  to  the 
patient,  but  there  is  no  lasting  value  to  be  obtained  thereby. 

The  Toxemia  of  Pneumonia.  Low,  muttering  delirium, 
rapid  pulse  and  leucopenia  are  a  severe  and  annoying  set 
of  symptoms  calling  for  prompt  and  vigorous  treatment. 

Here  the  patient  must  certainly  be  given  all  the  fresh  air 
possible.  Windows  must  be  opened  whatever  the  degree  of 
temperature  of  the  outside  air.  The  circulation  must  be  sup- 
ported by  strychnin  and  cafifein.  An  abundance  of  water 
by  mouth,  by  rectum,  under  the  skin,  or  directly  into  the 
veins  is  most  helpful.     It  is  just  this  phase  of  pneumonia  in 


CROUPOUS    PNEUMONIA.  Z7 

which  alcohol  in  some  form  has  been  so  widely  used,  and  is 
still  a  commonly  used  drug.  The  author  has  used  both  large  and 
small  doses  of  alcohol,,  in  the  form  of  whisky  and  brandy 
under  these  conditions,  and  after  observation  he  is  of  the 
opinion  that  a  case  of  severe  pneumonia  is  best  treated  zvith- 
out  the  use  o.f  large  doses  of  alcohol. 

In  a  recent  series  of  25  cases  at  St.  Timothy's  Hospital, 
Roxborough,  with  a  mortality  of  12  per  cent.,  all  alcohol  was 
withheld.  Many  of  the  cases  were  of  a  most  severe  type.  I 
recognize  that  the  number  of  these  cases  is  small,  too  small 
to  prove  a  rule,  but  their  behavior  was  better  than  that  of  an 
earlier  group  of  pneumonias  to  which  large  doses  of  alcohol 
were  given. 

Small  doses,  3^  ounce  (15  mils)  every  three  hours,  4 
ounces  (120  mils)  in  twenty-four  hours,  are  perhaps  of  value 
because  that  much  alcohol  can  be  used  as  a  food.  It  is 
apparently  burned  up  without  any  trouble,  and,  therefore,  is 
of  value. 

Abdominal  Distention.  This  symptom  is  probably  the 
result  of  the  toxemia,  and  it  is  best  combated  by  the  methods 
used  to  overcome  that  symptom.  In  addition,  salicylate 
of  eserin,  used  hypodermically,  is  of  value.  Pituitrin  will  also 
act  well  under  such  circumstances.  Turpentine  stupes  applied 
hot  to  the  abdomen  will  sometimes  give  relief.  A  rectal  tube 
may  also  be  kept  constantly  in  place  during  the  periods  of 
greatest  distention.  In  using  the  rectal  tube,  care  must  be 
taken  to  protect  the  bed,  because  frequently  thin  fecal  matter 
will  come  through  the  tube,  making  an  annoying  condition. 

Acute  Dilatation  of  the  Stomach.  This  condition  is  more 
frequently  a  complication  of  pneumonia  than  is  supposed.  It 
occurs  usually  just  after  the  crisis,  or  after  the  patient  seems 
well  on  his  way  to  recovery,  following-  lysis.  The  patient  is 
usually  obstinately  constipated,  shocked,  and  vomits  large 
amounts  of  ill-smelling  material  from  the  stomach.  There  is 
great  distention  of  the  abdomen,  especially  in  the  epigastrium, 
a  fullness  due  to  dilatation  of  the  stomach  with  liquid  and  gas, 
and  such  a  clinical  picture  is  frequently  mistaken  for  obstruc- 
tion of  the  intestines,  but  having  once  been  seen  and  recog- 
nized, it  is  easily  diagnosed  thereafter. 


38  SPECIFIC    INFECTIONS. 

For  this  accident  the  treatment  is  lavage.  Even  w^hen 
there  is  some  doubt  as  to  the  diagnosis,  the  passage  of  a 
stomach-tube  is  demanded.  The  tube  is  easily  swallowed, 
and  apparently  does  not  greatly  disturb  the  patient,  though 
he  seems  and  may  be  critically  ill.  On  the  contrary,  if  the 
diagnosis  is  correct,  the  relief  is  almost  instantaneous,  the 
pulse  becomes  better,  the  cyanosis  and  shock  less,  and  in  a 
short  time  the  patient  is  on  the  high  road  to  recovery.  If 
the  diagnosis  is  not  confirmed  by  the  use  of  the  tube,  the 
patient  is  not  in  the  least  harmed  by  its  passage,  and,  on  the 
contrary,  is  somewhat  relieved.  The  dilated  stomach  needs 
repeated  lavage,  frequently  about  every  twelve  hours  for  two 
or  three  days.  The  frequency  with  which  the  washing  is 
repeated,  and  the  time  over  which  it  must  be  continued, 
depend  upon  the  condition  of  the  patient.  If  the  symptoms 
are  entirely  relieved,  the  vomiting  does  not  return,  the  col- 
lapse and  constipation  are  overcome,  there  is  no  reason 
for  repetition  of  the  washing  of  the  stomach,  but  the  opera- 
tion must  be  continued  so  long  as  the  symptoms  continue. 

After  the  lavage  the  patient  must  be  placed  either  upon 
the  right  side  or  upon  the  face.  This  relieves  the  constriction 
of  the  intestine  which  always  occurs  in  these  cases,  whatever 
the  sequence  of  dilatation  of  the  stomach,  and  constriction 
under  the  mesenteric  notch.  The  relief  given  removes  the 
true  obstruction  which  occurs  at  this  spot. 

In  addition  to  the  measures  just  detailed,  the  hypodermic 
administration  of  eserin  hydrochlorate  or  sulphate  in  %4  grain 
(0.00270  Gm.)  doses  is  of  great  benefit  in  acute  gastric 
dilatation,  and  as  a  precautionary  step  the  fluid  intake  of  the 
patient  must  be  decidedly  curtailed. 

Nephritis,  Every  severe  case  of  pneumonia  shows  the 
presence  of  a  varying  amount  of  albumin  and  tube-casts  in 
the  urine.  This  is  not  of  moment.  However,  there  is  a  cer- 
tain number  of  cases  in  which  the  urine  is  much  diminished 
and  is  loaded  with  tube-casts  and  albumin.  Do  not  give  stim- 
ulating diuretics  in  these  cases.  Give  water,  limit  the  nourish- 
ment to  milk,  cup  the  loins,  and  use  heat  over  the  lumbar 
region. 

Pleurisy.  There  is,  perhaps,  no  case  of  croupous  pneu- 
monia which  is  not  accompanied  by  a  greater  or  less  inflam- 


CROUPOUS    PNEUMONIA.  39 

mation  of  the  pleura.  This  is  manifested  by  the  "stitch  in 
the  side,"  pain  on  deep  inspiration  in  the  adult,  and  by  the 
expiratory  grunt  of  the  afflicted  child.  A  friction  rub  can 
usually  be  demonstrated  by  auscultation. 

The  treatment  of  pleuritis  is  strapping  the  chest,  just  as 
would  be  done  in  a  broken  rib,  and  the  application  of  cold  in 
the  form  of  an  ice-bag  or  an  ice-coil.  The  use  of  either  dry 
or  wet  cups  gives  a  great  amount  of  relief.  If  the  pain  is 
severe,  the  administration  of  opium,  usually  as  morphin, 
hypodermically,  is  absolutely  necessary. 

This  simple  pleurisy  is  the  rule  in  pneumonia,  but  occa- 
sionally it  is  accompanied  by  a  serous  effusion.  The  treatment 
of  this  simple  serous  effusion,  which  occurs  during  the  height 
of  the  disease,  depends  upon  the  mechanical  effect  of  the 
effusion.  If  the  heart  is  not  much  displaced,  if  there  is  little 
embarrassment  of  breathing,  then  the  effusion  may  be  safely 
left  to  the  forces  of  nature  for  its  absorption.  If,  on  the  other 
hand,,  the  effusion  embarrasses  the  patient  in  any  way,  the 
fluid  should  be  aspirated  under  the  strictest  aseptic  precau- 
tions. 

If  this  tapping  of  the  chest  is  done  under  local  anesthesia, 
and  the  skin  incised  so  that  the  needle  will  easily  enter  the 
chest,  there  will  be  scarcely  any  disturbance  of  the  patient. 
On  the  other  hand,  if  the  needle  be  plunged  through  the  skin 
without  first  using  a  local  anesthesia  and  incising  the  skin, 
great  shock  may  be  produced.  The  writer  has  seen  death 
occur  as  the  result  of  such  a  shock. 

Purulent  Pleurisy.  When  the  temperature  of  a  case  of 
pneumonia  begins  to  rise  after  the  crisis  or  lysis,  or  when  the 
temperature  does  not  fall  after  eight  or  ten  days,  especially 
if  it  takes  on  the  character  of  an  increased  septic  fever,  and 
the  leucocytes  increase  in  number,  the  physician  knows  that 
the  patient  is  the  subject  of  some  active  inflammatory  com- 
plication. The  most  common  complication  of  this  kind  is 
empyema.  The  fluid  may  be  either  free  in  the  pleural  cavity 
or  confined  between  the  lobes,  or  between  the  lower  lobe  and 
the  diaphragm. 

Frequently  repeated  careful  examinations  of  the  chest  are 
necessary  to  locate  the  liquid.  If  it  is  free  in  the  pleural 
cavity  the  diagnosis  is  easy,  the  only  necessity  being  daily 


40  SPECIFIC    INFECTIONS. 

observation  of  the  naked  chest.  There  is  flatness  over  the 
chest,  decreased  tactile  fremitus,  and  loss  of  voice  sounds. 
The  heart  is  pushed  to  the  right  or  left,  the  liver  displaced 
downward,  if  the  effusion  is  on  the  right  side,  and  the  area 
of  gastric  t3'mpany  diminished  if  the  fluid  is  on  the  left  side. 
In  children  the  physical  signs  are  often  misleading.  A 
puncture  with  a  sterile  aspirating  needle  will  establish  the 
diagnosis.  The  diagnosis,  however,  is  not  so  clear-cut  and 
easy  if  the  liquid  is  confined  between  the  lobes.  In  this  con- 
dition the  flatness  is  frequently  localized  in  the  line  of  the 
interlobar  fissure.  There  is  lack  of  fremitus,  with  decreased 
voice  and  breath  sounds  over  this  area,  sometimes  accom- 
panied by  a  circumscribed  edema  of  the  skin.  If  there  is 
doubt  as  to  the  presence  of  liquid,  a  needle  should  be 
inserted  between  the  ribs  and  careful  search  made  with  the 
point  plunged  in  different  directions.  Unfortunately  for  this 
method  of  diagnosis,  the  needle  often  does  not  reach  the 
liquid,  even  although  the  physical  signs  are  positive.  The 
difficulty  is  that  either  the  needle  is  too  small  or  too  short 
or  has  not  reached  the  collection  of  pus.  If  the  patient  is  near 
an  .f-ray  apparatus,  a  good  stereoscopic  picture  should  be  taken 
in  order  to  prove  the  presence  or  absence  of  a  purulent  focus. 
Not  only  does  the  x-rsiy  show  the  shadow  of  the  pus,  but  it 
shows  its  exact  position.  The  presence  of  a  collection  of  pus 
being  once  established,  the  fluid  must  be  evacuated. 

This  operation  occasionally  is  the  simplest  of  procedures, 
and  may  be  done  by  any  physician  who  is  at  all  accustomed 
to  the  technic  involved.  But  it  is  by  all  odds  the  safest  plan 
to  send  such  a  patient  to  a  hospital  and  have  the  chest  care- 
fully exposed  under  anesthesia.  One  word  of  caution  :  When 
the  patient  is  a  child  and  the  chest  is  full  of  liquid  under  much 
tension,  the  sudden  withdrawal  of  the  liquid  by  means  of  an 
incision  is  often  followed  by  a  severe  shock,  sometimes  even 
by  fatal  collapse.  Therefore,  it  is  a  safe  rule  to  tap  first,  and 
afterward  to  drain  surgically. 

Arthritis.  Certain  cases  of  pneumonia  are  followed  by 
arthritis,  or  the  inflammation  of  the  joint  may  occur  during 
the  height  of  the  disease.  It  must  be  remembered  that  these 
attacks  of  pain  and  swelling  of  the  joints  signify  a  localiza- 
tion of  the  toxin,  or,  perhaps,  of  the  pneumococci  themselves. 


CROUPOUS    PNEUMONIA.  41 

The  treatment  is  fixation  of  the  joint  and  the  application  of 
a  cool  evaporating-  liquid,  such  as  lead-water  and  laudanum, 
or  saturated  solution  of  magnesium  sulphate.  Occasionally 
the  joint  becomes  purulent,  and  in  this  event  the  surgeon's 
aid  is  to  be  enlisted. 

Middle-ear  Disease.  This  condition  often  appears  insid- 
iously, particularly  if  the  patient  be  very  ill.  The  ears  should 
be  regularly  examined,  and  particularly  if  there  is  an  unac- 
countable rise  of  temperature  or  a  continuance  of  temperature 
after  it  should  normally  fall.  If  the  ear-drum  bulges,  it  should 
at  once  be  punctured. 

Meningitis.  This  is  an  inflammation  of  the  meninges  due 
to  the  presence  of  pneumococci  in  the  cerebrospinal  axis.  It 
is  manifested  by  the  ordinary  symptoms  of  meningitis,  stiff- 
ness of  the  neck  and  back,  delirium  and  Kernig's  sign.  It 
may  be  confused  with  the  so-called  meningismus,  due  to  the 
irritation  of  the  meninges  by  the  pneumotoxin.  The  diag- 
nosis is  made  by  spinal  puncture,  and  the  best  treatment  is 
this  same  puncture  repeated  every  twenty-four  hours,  or  even 
oftener  if  symptoms  demand  it. 

Treatment  of  the  Crisis.  When  the  crisis  occurs  the 
patient  is  getting  well.  There  is  no  danger  of  collapse  on 
account  of  the  suddenly  lowered  temperature.  On  the  con- 
trary, the  pulse  drops  in  frequency,  and  the  heart  becomes 
slower  and  more  forcible.  The  patient  expresses  himself  as 
feeling  well.  Therefore,  the  only  treatment  is  to  see  that 
because  he  feels  so  well  he  does  not  abuse  his  condition  by 
attempting  to  sit  up,  by  much  talking,  or  by  other  undue 
exertion.     Stimulants  are  rarely  ever  needed. 

THE  USE  OF  EFFICIENT  DRUGS. 

Digitalis.  This,  in  the  writer's  experience,  is  the  most 
useful  single  drug  in  all  cases  of  pneumonia  with  an  organic 
heart  disease.  Digitalis  should  be  given  from  the  beginning 
of  the  attack  in  moderate  doses,  10  drops  (0.6  mil)  of  a  good 
tincture  three  times  in  the  twenty-four  hours.  This  dose  can 
be  increased  if  the  heart  shows  signs  of  dilatation;  10  drops 
(0.6  mil)  used  by  the  mouth  or  hypodermically  can  be  given 
every  three  hours,  care  being  taken  that  the  quantity  given 
is  not  large  enough  to  cause  poisoning  by  this  most  useful 


42  SPECIFIC   INFECTIONS. 

drug.  Remember  that  when  one  uses  digitalis  one  does  so 
because  the  patient  surely  needs  help.  Therefore,  see  that 
the  digitalis  is  obtained  from  a  source  which  will  insure  a 
potent  article.  Good  digitalis  may  be  life-saving,  while  a 
worthless  drug  may  sacrifice  a  life  that  otherwise  could  be 
saved. 

Strychnin.  Pharmacologists  tell  us  that  strychnin  neither 
raises  the  blood-pressure  nor  stimulates  the  heart.  Be  that  as 
it  may,  doses  of  Y^q  grain  (0.00216  Gm.)  every  three  or  four 
hours,  used  hypodermically,  are  of  great  value.  The  patient 
rests  better,  his  pulse  is  stronger,  and  he  is  distinctly  improved 
by  its  use.  Therefore,  in  severe  cases  where  there  is  toxemia, 
and  where  the  circulation  is  poor,  I  believe  that'  full  doses  of 
strychnin  are  not  only  indicated,  but  are  useful. 

Morphin,  in  violent  delirium,  wh&n  the  patient  is  restless 
from  his  toxemia,  when  he  has  pain  from  his  pleurisy,  is  of  the 
greatest  value.  It  should  be  used  with  caution,  however,  care 
being  taken  to  avoid  narcosis. 

Atropin.  This  drug,  used  when  there  is  a  tendency  to 
edema  of  the  lungs,  is  of  much  value.  It  should  be  used  in 
doses  of  YiQQ  of  a  grain  (0.00065  Gm.),  repeated  every  two  or 
three  hours  if  necessary. 

Caffein.  The  alkaloid  in  2-  or  3-  grain  (0.13  or  0.195 
Gm.)  doses  by  the  mouth,  or  caffein  sodium  benzoate  hypo- 
dermically, is  of  value  when  the  patient  is  weak,  either  from 
grave  toxemia  or  from  failure  of  the  circulation. 

Camphor.  In  the  form  of  camphorated  oil  used  hypoder- 
mically, 1  or  3  grains  (0.065  or  0.195  Gms.)  of  camphor  every 
one  or  two  hours  is  useful.  It  is  by  no  means  a  specific,  but 
sometimes  will  help  to  lift  the  patient  over  the  incline. 

Nitroglycerin.  This  is  a  much  abused  drug.  It  is  not  a 
heart  stimulant.  The  pulse  becomes  fuller  after  its  use,  but 
this  is  because  the  peripheral  vessels  a.re  dilated.  It  is  of 
apparent  use  when  the  heart  is  laboring  and  fighting  against 
a  high  pressure.  Then  the  peripheral  vessels  are  enough 
dilated  by  the  use  of  the  drug  to  allow  the  heart  to  become 
more  efficient.  Cyanosis,  with  a  laboring  right  heart,  are  the 
indications  for  its  use.  It  should  be  used  in  full  doses  for  a 
short  time.     It  should  not  be  used  in  severe  toxemia. 


CATARRHAL   PNEUMONIA.  43 

Oxygen.  This  gives  relief  to  the  patient  with  much 
cyanosis  and  laboring-  heart.  The  respirations  are  quieted, 
and  the  heart  labors  less.  It  is  a  good  adjunct  to  fresh  air. 
Fresh  air,  however,  will  usually  make  its  use  unnecessary. 

Calomel.  If  there  is  much  abdominal  distention,  this  will 
do  good  by  causing  free  bowel  movements,  and  by  apparently 
lessening  the  tendenc)--  to  fermentation  in  the  intestinal  tract. 

Eserin  and  Pituitary  Extract.  These  are  of  value  where 
there  is  much  abdominal  distention.  They  appear  to  cause 
the  expulsion  of  gas  from  the  intestinal  tract  by  stimulating 
the  muscular  coat  of  the  gut. 

CATARRHAL    PNEUMONIA. 

Catarrhal  pneumonia  is  a  bacterial  disease  affecting  the 
lobules  of  the  lung.  It  differs  from  croupous  pneumonia  in 
several  respects.  The  various  groups  of  bronchopneumonia 
have  a  dift'erent  beginning  from  those  of  croupous  pneumonia. 
While  croupous  pneumonia  begins  suddenly,  with  chills,  high 
fever,  and  rapid  respiration,  only  in  exceptional  cases  of  bron- 
chopneumonia does  this  sequence  occur. 

Certain  cases,  particularly  in  children,  and  occasionally  in 
adults,  begin  acutely,  just  as  cases  of  croupous  pneumonia  do. 
These  cases,  however,  are  much  rarer  than  are  the  ordinary 
ones  of  bronchopneumonia  which  follow  fevers,  such  as 
measles,  whooping-cough,  influenza,  scarlet  fever,  and  so 
forth.  The  bacteriology  of  this  disease  also  dift'ers  from  that 
of  croupous  pneumonia.  In  croupous  pneumonia^  the  largest 
number  of  cases  are  due  to  one  or  the  other  types  of  pneu- 
mococcus,  whereas,  in  catarrhal  pneumonia,  the  influenza  bacil- 
lus, the  micrococcus  catarrhalis,  the  pneumococcus,  Friedlan- 
der's  bacillus  and  various  streptococci  are  very  much  more  fre- 
quently the  etiologic  factors. 

Three  divisions  of  this  bronchopneumonia  are  usually 
recognized — the  acute  type,  which  resembles  xery  closely  in 
its  symptoms  and  course  croupous  pneumonia ;  the  form  which 
follows  infectious  fevers,  such  as  measles,  scarlet  fever,  diph- 
theria, influenza  and  whooping-cough  ;  and  the  so-called  aspira- 
tion pneumonia,  which  is  likely  to  follow  certain  depressing 
states,  in  cases  of  etherization,  and  particularly  in  older  in- 
dividuals with  nose  and  throat  conditions. 


44  SPECIFIC    INFECTIONS. 

The  symptomatology  of  the  acute  cases  is  very  much  the 
same  as  that  of  croupous  pneumonia,  and  the  course  is  very 
much  the  same.  The  ordinary  bronchopneumonia  which  fol- 
lows measles,  whooping-cough^  influenza,  inflammation  of  the 
lungs,  is  limited  to  smaller  areas.  The  inflammation  begins 
usually  in  the  smaller  bronchi,  and  in  the  lobules  of  the  lung. 
The  primary  condition,  for  instance,  may  be  progressing  nor- 
mally, and  even  begin  convalescence,  when  the  temperature 
rises,  the  course  of  the  disease  becomes  prolonged,  the  child 
begins  to  cough  more  frequently,  a  leucocytosis  occurs,  and 
one  realizes  that  one  is  in  the  presence  of  some  complication. 
Coincident  with  this  increase  of  symptoms,  and  particularly 
the  pulmonary  symptoms,  physical  signs  may  make  their  ap- 
pearance in  the  lung.  Here  there  are  small  areas  of  dullness, 
scattered  in  various  portions  of  the  lungs,  larger  or  smaller, 
depending  upon  the  severity  of  the  disease  and  the  portion  of 
the  lung  affected. 

If  these  areas  are  isolated  and  large  enough,  blowing 
breathing,  together  with  increased  fremitus,  and  increased 
vocal  resonance  may  be  part  of  the  physical  signs.  The  pulse 
becomes  rapid,  the  respiration  more  frequent,  and  the  child 
cyanosed.  With  the  progress  of  the  disease  the  cyanosis  in- 
creases, urgent  dyspnea  occurs,  and  the  child'  may  die  of 
respiratory  failure,  due  to  involvement  of  large  areas  of  the 
lung. 

The  disease  is  often  prolonged  for  several  weeks,  far  beyond 
the  time  at  which  a  croupous  pneumonia  begins  to  resolve. 
Then  the  question,  as  to  whether  the  subject  has  tuberculosis 
or  not  becomes  a  very  grave  one.  In  the  majority  of  cases,  this 
can  be  settled  only  by  the  termination  of  the  case  into  com- 
plete health,  or  by  a  frank  tuberculous  process  in  the  lung. 

As  a  preventive  measure  of  bronchopneumonia  in  a  child 
sick  with  an  exhausting  disease  like  measles,  diphtheria,  or 
influenza,  the  room  in  which  they  are  nursed  should  be  well 
ventilated,  and  the  child  carefully  protected  from  draft.  The 
chilling  of  the  body  apparently,  has  much  to  do  with  the  onset 
of  the  pneumonia  in  certain  areas  of  the  lung.  If  the  child  is 
protected,  however,  the  temperature  of  the  room  does  not  need 
to  be  of  a  unif6rm  character. 


CATARRHAL   PNEUMONIA.  45 

TREATMENT. 

The  general  principles  of  treatment  differ  little,  if  at  all, 
from  those  applied  to  the  treatment  of  croupous  pneumonia. 
The  patient  should  be  kept  in  bed  in  the  fresh  air,  the  windows 
of  the  room  being  wide  open.  The  patient  should  be  thor- 
oughly protected  from  chilling  by  the  use  of  proper  bed  cloth- 
ing, and  proper  underclothing,  such  as  combination  drawers  if 
he  is  a  child,  and  if  the  weather  is  very  cold,  a  cap  should  be 
placed  on  the  head,  and  mittens  on  the  hands.  The  drawers 
should  be  made  with  stocking  feet,  so  that  in  case  the  child 
becomes  uncovered,  the  body  will  still  be  protected  by  a  set 
of  drawers. 

The  child  should  be  given  an  abundance  of  water,  simply 
as  a,  method  of  lessening  the  intoxication,  and  he  should  be 
fed  milk  and  soft  foods  such  as  toast,  eggs,  junket,  and  mashed 
potatoes.  The  use  of  alcohol  in  this  condition,  follows  the 
same  rules  as  the  use  of  alcohol  in  other  infections — it  should 
be  given  in  amounts  large  enough  to  act  as  a  food.  For  a  child 
5  years  old  a  half  an  ounce  (15  mils)  in  twenty-four  hours  is 
an  abundance.     Larger  doses  depress  rather  than  stimulate. 

As  the  disease  is  likely  to  be  prolonged,  particularly  in  the 
secondary  cases,  the  fever,  which  may  last  two  or  three  weeks, 
reaching  102°  or  103°  F.  (38.9°  or  39.2°  C),  should  be  ade- 
quately controlled,  the  best  method  being  by  sponging,  or  by 
tubbing.  The  temperature  of  these  sponges  and  baths  should 
be  relatively  high,  from  90°  to  100°  F.  (32.2°  to  37.8°  C).  Coal 
tar  preparations  should  never  be  used,  inasmuch  as  they  de- 
press the  heart,  and  do  more  harm  than  good. 

Applications  to  the  chest  are  of  some  value.  AVhen  the 
child  is  much  depressed  by  a  great  degree  of  diffuse  bronchitis, 
as  evidenced  by  rapid  breathing  and  many  rales  over  the  entire 
chest,  applications  of  mustard  water  to  the  chest,  afterward 
surrounding  the  chest  with  a  padded  cotton  jacket,  often 
causes  such  local  irritation  in  the  skin,  that  the  congestion  of 
the  lung  is  apparently  relieved.  The  old-fashioned  flaxseed 
poultice  entirely  surrounding"  the  chest  is  of  value  in  advanced 
cases.  More  valuable  than  these  flaxseed  poultices,  l)ecause 
more  easily  applied,  is  the  quilted  cotton  jacket  surrounded  by 
oiled  silk  or  oiled  muslin.    This  is  closely  applied  to  the  child's 


46  SPECIFIC    INFECTIONS. 

chest,  and  makes  a  veritable  poultice  in  a  very  short  time. 
This  jacket  should  be  frequently  changed  for  cleanliness  sake, 
and  while  it  is  being  changed,  the  skin  should  be  rubbed  thor- 
oughly with  alcohol  or  with  a  weak  mustard  water.  When  the 
child's  breathing  is  much  oppressed,  when  he  is  cyanosed,  when 
the  same  fine  subcrepitant  rales  are  heard  over  the  entire 
chest,  intermittent  dipping  in  warm  and  cold  water  will  occa- 
sionally bring  about  so  much  relief,  that  the  child  may  act- 
ually be  turned  toward  the  road  to  recovery,  instead  of  going' 
down  hill  as  he  apparently  was  about  to  do.  A  bath  about  a 
temperature  of  110°  F.  (43.3°  C),  and  another  one  of  a  tem- 
perature of  about  85°  or  90°  F.  (28.9°  or  32.2°  C.)  is  useful. 
The  child  is  first  stripped,  dipped  into  the  tepid  bath,  and  then 
quickly  dipped  into  the  colder  bath,  then  into  the  tepid  and 
again  into  the  cold.  In  this  way  deep  inspirations  are  forced, 
and  the  exudate  is  cleared  from  the  small  bronchi ;  the  child 
again  breathes  easil3^  I  am  quite  sure  that  I  have  seen  life 
saved  by  this  method  of  treatment,  when  the  condition  was  as 
stated. 

Internal  medicines  are  of  value.  Just  how  to  use  them,  and 
just  how  much  to  use,  however,  is  a  question  depending-  upon 
each  individual  patient.  Two  drugs  it  seems  to  me  are  of 
paramount  importance :  chlorid  of  ammonium,  and  carbonate 
of  ammonium,  in  cases  where  there  is  a  sticky,  viscid  exudate, 
and  the  chest  is  full  of  fine  rales.  These  drugs  given  in  proper 
doses,  well  diluted,  relieve  this  condition  very  markedly.  A 
child  three  and  one-half  years  old  should  get  1^  to  2  grains 
(O.OSO  to  0.120  Gm.)  of  chlorid  of  ammonium,  or  1  grain  (0.065 
Gm.)  of  carbonate  of  ammonium,  repeated  every  two  or  three 
hours  according  to  the  condition  of  the  case.  Citrate  of 
potassium,  under  certain  conditions,  in  3-grain  (0.195  Gm.) 
doses  is  of  value.  It  softens  up  the  mucus  and  viscid  exudate, 
and  relieves  the  case  in  this  way.  Where  the  bronchitis  rapidly 
increases,  and  spreads  over  both  lungs,  the  use  of  atropin  in 
the  form  of  tincture  of  lielladonna,  is  often  of  the  gxeatest 
value.  It  dries  up  the  mucus,  which  often  is  not  the  result  of 
an  actual  inflammation,  but  represents  rather  of  an  exudate 
into  the  bronchi,  and  in  that  way  clears  the  bronchial  tubes. 

When  the  heart  is  rapid  and  dilated,  the  use  of  digitalis  is 
of  the  greatest  importance.     I  am  quite  sure  that  I  have  seen 


PYOGENIC    INFECTIONS.  47 

cases  recover  by  doubling  the  dose  of  digitalis  and  belladonna, 
which  were  being  steadily  given.  This  of  course  can  be  judged 
only  by  the  dilatation  of  the  heart,  and  by  the  amount  of  ob- 
struction to  the  breathing. 

Strychnin,  in  a  dose  of  %20  of  a  grain  (0.00365  Gm.)  every 
three  hours,  in  a  child  three  or  four  years,  is  a  dependable  drug, 
but  care  must  be  taken  not  to  give  enough  to  cause  poisonous 
symptoms. 

When  a  child  coughs  constantly,  frequent  stimulation  of 
the  chest  wall  by  mustard  baths,  or  by  a  poultice  containing 
small  amounts  of  mustard,  very  often  relieves  the  cough. 
Great  care  should  be  used  in  the  administration  of  opiates 
under  these  conditions,  and  the  milder  opiates  should  always 
be  chosen.  The  best  one  is  paregoric.  The  dose  of  this  is  so 
easily  regulated,  that  there  is  little  danger  of  giving  an  over- 
dose, as  there  would  be  if  morphin,  or  one  of  the  other  alka- 
loids was  used.  Ten  to  fifteen  drops  (0.8  to  1  mil)  of  paregoric 
to  a  child  two  years  old,  given  every  three  hours,  will  be  suffi- 
cient, for  the  first  dose.  If  this  does  not  control  the  cough  and 
if  there  is  no  sign  of  narcosis,  then  begin  gradually  to  increase 
the  dose  two  or  three  drops  at  each  dose,  until  some  effect  is 
produced.  But  I  think  the  use  of  opiates  is  generally  contra- 
indicated  in  children  with  this  condition.  The  opium  seems 
to  lessen  the  response  of  the  respiratory  centers  to  stimulation, 
and  makes  the  patient  less  able  to  expectorate. 

When  the  cyanosis  is  extreme,  the  use  of  oxygen  is  of 
value,  but  there  is  no  oxygen  quite  so  good  as  the  use  of  pure, 
circulating,  fresh  air,  with  the  child  thoroughly  protected 
against  chilling  of  the  surface  of  the  body. 

PYOGENIC    INFECTIONS. 
(Septicemia,   Pyemia,   Toxemia.) 

This  infection  has  its  origin  in  any  lesion  of  the  body,  be 
it  superficial  or  deep,  which  becomes  infected  with  any  of  the 
pyogenic  bacteria.  A  mere  scratch  on  the  skin,  if  a  virulent 
streptococcus  becomes  implanted  and  grows,  may  give  rise  to 
the  most  violent  fever,  chills,  exhaustion,  and  even  death. 

The  streptococcus  is  not  the  only  invading  micro-organ- 
ism, however,  for  any  pathogenic  bacteria,  such  as  staphylo- 


48  SPECIFIC    INFECTIONS. 

cocci,  gonococci,  colon  bacilli  and  pneumococci  may  give  rise 
to  the  most  violent  symptoms,  the  streptococcus  and  the 
staphylococcus  being  the  most  frequent  invading  micro-or- 
ganisms. •  Puerperal  fever  is  simply  an  infection  in  which  the 
seat  of  the  disease  is  the  female  genital  tract,  the  germs  get- 
ting their  lodgment  from  uncleanly  nurses  or  obstetricians, 
although  occasionally  some  local  lesion  present  before  labor 
is  the  primary  cause. 

Septicemia  is  the  name  given  to  the  condition  where  there 
is  an  infection  of  the  blood-stream  arising  from  some  primary 
focus,  and  where  there  are  no  secondary  abscesses  consequent 
to  the  bacteremia. 

Pyemia  always  results  from  a  septicemia,  and  the  name 
pyemia  is  applied  to  a  condition  of  multiple  foci  of  infection 
resulting  from  the  original  septic  infection.  Septic  endocar- 
ditis is  but  a  phase  of  pyemia.      / 

The  term  toxemia  is  applied  to  the  condition  in  which  the 
symptoms  are  due  to  toxins  which  result  from  the  multiplica- 
tion or  breaking  down  of  the  bacteria,  or  destruction  of  the 
cellular  elements  of  the  body. 

The  mortality  of  septicemia  and  pyemia  resulting  from  the 
streptococcus  and  staphylococcus  is  extremely  high,  accord- 
ing to  Pearce  and  Austin — 83  to  88  per  cent.  If  the  mul- 
tiple abscesses  form  in  the  internal  organs  such  as  the  liver, 
kidney,  spleen  and  brain,  pyemia  almost  always  has  a  fatal 
ending. 

TREATMENT. 

Prophylaxis  is  perhaps  the  most  important  part  of  the 
treatment,  and  to  insure  this  prevention  of  pyemia  prompt 
surgical  treatment  of  superficial  wounds  is  imperative.  Asep- 
sis in  the  conduct  of  surgical  and  obstetrical  operations  are 
of  the  first  importance  as  a  prophylactic  safeguard. 

A  mere  scratch  may  give  rise  to  fatal  consequences  by  the 
time  the  original  wound  is  brought  to  the  attention  of  the 
general  practitioner.  Such  a  wound  should  be  treated  thor- 
oughly, being  opened  far  beyond  the  limits  of  the  original 
abrasion,  and  thoroughly  sterilized  with  antiseptic  solutions, 
and,  if  necessary,  with  iodin. 

Fear  of  giving  pain  should  not  interfere  with  the  free  use 
of  a  sterile  scalpel.     This  is  especially  important  where  the 


PYOGENIC    INFECTIONS.  49 

wound  has  been  contaminated  by  street  dirt  and  a  potential 
tetanus  infection  may  be  implanted. 

No  physician  should  undertake  the  simplest  surgical  opera- 
tion, to  say  nothing-  of  major  operations,  unless  he  uses  every 
precaution  to  prevent  infection  of  the  otherwise  clean  wound. 
No  physician  should  attempt  to  conduct  the  simplest  labor 
case  unless  he  recognizes  that  his  handling  of  the  genital 
tract  of  the  patient  may  give  rise  to  septicemia,  and  unless 
he  views  the  case  as  one  of  major  surgical  importance. 

After  infection  has  taken  place,  the  original  seat  of  inva- 
sion must  be  thoroughly  exposed,  drained,  and  packed,  if  such 
procedure  is  in  keeping  with  the  safety  of  the  patient.  If  the 
origin  of  the  infection  is  about  the  teeth,  these  should  be  sub- 
jected to  the  most  thorough  treatment,  even  to  their  extrac- 
tion. If  the  orig'inal  site  is  in  the  genitourinary  tract,  this 
must  be  flushed  by  irrigation  of  the  bladder  and  sometimes  of 
the  pelvis  of  the  kidney. 

,  General  treatment  must  at  once  be  instituted. 

Free  use  of  fresh  air,  sunlight,  and  the  drinking  of  large 
amounts  of  water  are  the  best  means.  The  temperature  must 
be  controlled  by  the  circulation  of  fresh  air,  and  the  applica- 
tion Of  cold  to  the  surface  of  the  body  by  means  of  cold 
sponging  or  cold  baths  is  to  be  made. 

Coal-tar  preparations  must  never  be  used.  They  will 
lower  the  temperature,  but  they  do  harm.  Water  may  be 
used  by  the  mouth,  by  enteroclysis,  and  by  intravenous 
injections. 

Alcohol  in  small  quantities  may  be  given,  but  it  is  harm- 
ful if  given  in  intoxicating  doses. 

Food  is  of  the  highest  importance.  Large  quantities  of 
milk  should  be  used. 

Strychnin,  in  doses  of  '^q  grain  (0.002  Gm.),  every  three 
hours,  is  useful. 

Digitalis  may  be  used  either  hypodermically  or  by  the 
mouth. 

Lately  the  use  of  foreign  porteids  in  the  form  of  killed 
bacilli  of  almost  any  type  have  been  used  with  apparent  good 
effect  in  certain  localized  infections,  especially  in  the  cases  of 
uncontrolled  arthritis.  Given  in  small  quantities  into  the 
vein,  it  is  followed  by  a  severe  reaction,  often  bv  a  chill  and 

4 


50  SPECIFIC   INFECTIONS. 

high  fever.  After  the  subsidence  of  the  reaction  there  is  a 
remarkable  amelioration,  but  unless  the  cause  is  removed  the 
conditions  return. 

In  certain  local  infections  the  use  of  autogenous  vaccines 
has  proven  of  signal  value.  However,  the  type  of  the  micro- 
organism must  first  be  ascertained,  if  any  hope  of  a  specific 
cure  is  to  be  realized.  Without  a  knowledge  of  the  character 
of  the  infecting  germ,  and  without  the  certainty  that  the  bac- 
teria in  the  vaccine  and  the  infecting  focus  are  of  the  same 
character,  vaccine  treatment  is  a  slipshod,  uncertain  method 
of  therapeutics,  and  should  not  be  used. 

Vaccine  therapy,  to  be  of  value,  must  be  exact,  and  any 
other  method  of  its  use  is  highly  irrational. 

In  diphtheria,  tetanus,  epidemic  meningitis,  and  possibly 
in  influenza  and  cholera,  the  sera  are  specific  and  life-saving. 
In  streptococcemia  they  have  not  been  proved  of  value  be- 
cause of  the  weakness  of  the  sera,  and  because  of  the  uncer- 
tainty that  the  sera  are  made  of  the  same  strain  as  the  infect- 
ing organism. 

COLON-BACILLUS   INFECTIONS. 

The  colon  bacillus  is  a  normal  inhabitant  of  the  healthy 
human  intestine,  but  under  certain  conditions  the  micro- 
organism becomes  pathogenic,  and  may  give  rise  to  a  local 
infection  or  to  a  general  disease.  Infections  of  the  bladder 
and  kidney,  certain  forms  of  arthritis  and  synovitis  are 
familiar  examples  of  the  local  colon  infection.  Other  cases 
give  rise  to  a  general  infection  characterized  by  rather  long- 
continued,  inexplicable  fever. 

The  diagnosis  of  a  colon  infection  can  be  made  only  by 
agglutination  reactions,  and  by  recovery  of  the  bacillus  from 
the  blood  of  the  patient,  or  from  the  seat  of  the  local  infection. 

In  all  cases  of  arthritis,  cystitis,  pyelitis,  cirrhosis  of  the 
liver,  severe  anemia  and  gall-bladder  disease,  and  in  all  cases 
of  fever  entirely  inexplicable  in  type,  it  must  be  remembered 
that  the  colon  bacillus  may  be  the  bacterium  responsible  for 
the  clinical  picture  of  the  patient  under  consideration. 

The  treatment  of  a  general  colon  infection,  which  often 
closely  resembles  typhoid  fiiver  in  its  symptoms  and  course. 


DIPHTHERIA.  51 

must  be  based  upon  the  general  lines  of  treatment  of  that 
disease. 

The  use  of  an  autogenous  vaccine  may  possibly  serve  as 
a  certain  antidote. 

Local  infections,  such  as  cystitis  and  pyelitis,  may  be 
diagnosed  by  examination  under  proper  precautions  of  the 
bladder  and  renal  pelvis,  and  by  the  study  of  cultures  made 
from  the  exudate  from  these  parts.  If  they  are  found  to  be 
due  to  a  colon  bacillus,  autogenous  vaccines  may  be  used  with 
a  certain  expectation  of  success.  Large  amounts  of  water  and 
freedom  from  irritating  food  will  be  of  value. 

If  the  case  is  one  of  a  chronic  disorder,  such  as  cirrhosis 
of  the  liver,  anemia  or  changes  in  the  spinal  cord,  evacuation 
of  the  intestinal  tract,  the  daily  use  of  high  colon  irrigations 
and  the  administration  of  mineral  oil  may  be  found  of  beneht 
in  controlling  the  infection.  While  there  are  certain  well- 
defined  and  positive  cases  of  colon  infection,  the  subject  lends 
itself  to  much  misinterpretation.  The  laity,  always  naturally 
desirous  for  the  knowledge  of  the  name  of  his  ailment  and 
for  its  cause,  will  readily  grasp  at  "colon  infection,"  whether 
the  title  is  justified  or  not.  Hence,  the  conscientious  phy- 
sician will  be  as  certain  as  possible  of  his  data  before  he 
announces  the  name  of  the  illness  to  the  patient. 

DIPHTHERIA.* 

Diphtheria  is  an  acute  contagious  disease  caused  by  the 
Klebs-Lofiier  bacillus.  It  is  characterized,  clinically,  by  the 
formation  of  a  membrane  almost  always  upon  the  upper 
respiratory  tract  (pharynx,  larynx  and  nose),  and  by  second- 
ary systemic  changes  resulting  from  bacterial  toxins.  Other 
portions  of  the  body,  such  as  mucous  and  serous  membranes 
and  wounds,  may  harbor  the  bacteria  locally,  and  it  has  been 
stated  that  a  diphtheritic  toxemia  may  exist  without  the  actual 
presence  of  a  membrane.  These  are  rare,  and  unusual  mani- 
festations of  the  disease.  In  common  parlance,  diphtheria 
refers  to  an  angina  caused  by  the  Klebs-Ldffler  bacillus  with 
the  resultant  diphtheritic  toxemia. 


By  S.  S.  Woody,  M.D. 


52  SPECIFIC   INFECTIONS. 

The  Klebs-Loffler  bacillus,  first  described  in  1883,  varies 
greatly  in  different  cultures  and  strains,  and  expert  knowledge 
is  often  required  to  distinguish  some  of  the  more  unusual 
forms,  it  is  doubtful  whether  diphtheria,  as  a  clinical  entity, 
should  ever  be  diagnosed  by  culture  alone  in  the  absence  of 
the  general  clinical  signs  of  the  disease. 

Diphtheria  is  endemic  in  all  the  large  communities  in 
America  and  most  parts  of  Europe.  At  times  it  may  become 
epidemic,  and  this  may  occur  also  in  smaller  communities  and 
institutions.  It  is  more  prevalent  in  winter  than  in  summer. 
It  affects  all  ages  and  both  sexes.  It  is  largely,  however,  a 
disease  of  children  under  10  years  of  age,  although  its  occur- 
rence in  adults  and  older  children  is  by  no  means  rare.  Very 
young  children  may  be  affected  by  the  disease,  even  infants 
but  a  few  months  of  age.  It  is  about  equally  divided  between 
the  sexes,  although  some  observers  have  stated  it  to  be  more 
prevalent  amongst  girls. 

Diphtheria  is  transmitted  from  one  patient  to  another  by 
means  of  the  buccal,  pharyngeal  and  nasal  discharges.  It  may 
be  transmitted  directly,  as  is  more  often  the  case,  or  indirectly 
by  means  of  intermediate  carriers,  animate  or  inanimate.  The 
disease  must  be  considered  communicable  as  long  as  virulent 
diphtheria  bacilli  exist  at  the  site  of  a  given  lesion.  Certain 
outbreaks  of  diphtheria  have  been  traced  apparently  to  in- 
fected milk.  Mild  unrecognized  cases  of  diphtheria  are  per- 
haps amongst  the  most  important  factors  in  the  continued 
prevalence  of  a  disease  so  successfully  treated  when  recognized. 

The  local  pathologic  lesion  produced  by  the  diphtheria 
bacillus  is  the  formation  of  a  membrane,  consequent  to  the 
process  of  coagulation  necrosis.  This  membrane  finds  its 
most  frequent  seat  upon  the  tonsils  and  fauces,  and  by  exten- 
sion spreads  to  the  nose,  larynx,  and  even  to  the  trachea  and 
bronchi.  The  inflammation  of  the  tonsils  and  pharynx  is,  in 
general,  deeper  and  more  severe  than  that  of  the  larynx  or 
bronchi.  Implication  of  the  mouth  is  rare.  The  other  local 
complication  is  otitis,  which  may  be  complicated  by  mas- 
toiditis. The  latter  condition,  however,  is  exceedingly  rare. 
Cervical  adenitis  is  not  uncommon. 

The  lesions  due  to  the  diphtheria  toxins  are  many  and 
important.     Renal  complication,  either  as  an  albuminuria  or 


DIPHTHERIA.  53 

as  a  true  nephritis,  is  common.  The  liver  and  spleen  are  often 
involved.  Myocarditis  is  common.  The  most  characteristic 
general  lesion  of  diphtheria  is  an  inflammation  of  the  nerve 
roots  and  sheaths,  leading  to  palsies  of  various  kinds.  Pneu- 
mogastric  degeneration  is  not  uncommon. 

The  symptoms  of  diphtheria  vary  with  the  severity  of  the 
disease,  and  the  locality  and  extent  of  the  lesions.  Briefly 
stated,  the  cardinal  early  symptoms  are  sore  throat  accom- 
panied by  fever,  v\diich,  however,  is  not  usually  of  very  high 
range.  The  pulse  is  comparatively  rapid,  and  after  the  onset 
of  the  disease,  is  not  as  strong  as  in  many  other  acute  fel^rile 
conditions  of  the  same  temperature  range. 

The  diagnosis  is  made  by  the  appearance  of  the  charac- 
teristic membrane.  Usually  appearing  first  upon  the  tonsils 
and  spreading  therefrom,  it  shows  itself  as  a  whitish-gray 
membrane  or  film.  If  seen  before  this  membrane  appears,  the 
throat  shows  an  erythema,  and  may  be  positive  to  culture. 
The  membrane,  beside  extending,  may  change  in  color  some- 
what. In  any  event,  it  is  usually  quite  adherent.  In  cases 
untreated  by  antitoxin  the  membrane  begins  to  free  itself 
within  five  to  seven  days.  When  antitoxin  is  used  in  adequate 
dosage,  the  progress  of  the  disease  is  arrested,  and  separation 
of  the  membrane  begins  to  take  place  within  a  few  hours. 

Constitutional  symptoms — that  is,  those  of  toxemia  and 
cardiac  weakness — are  noted  early,  unless  the  case  be  of  the 
very  mildest  type. 

The  most  frequent  clinical  complications  are  cardiac  fail- 
ure, paralyses,  and  broncho-pneumonia  in  the  laryngeal  types. 

The  diagnosis  rests  upon  a  double  base.  Besides  the  clin- 
ical signs  mentioned,  we  have  an  aid  in  the  making  of  smears 
and  cultures  from  the  infected  areas.  These  are  of  the  great- 
est assistance  when  correctly  made,  but  in  the  hands  of  the 
inexperienced  often  lead  to  error. 

The  differential  diagnosis  of  diphtheria  offers  but  one  seri- 
ous difficulty.  In  certain  cases  of  scarlet  fever  the  angina 
resembles  that  of  diphtheria  to  such  an  extent  that  differen- 
tiation must  be  made  by  repeated  culture  or  by  the  accom- 
panying clinical  picture  of  scarlet  fever.  It  must  not  be 
forgotten  that  scarlet  fever  and  diphtheria  not  infrequentiv 
co-exist.      Various   forms   of  tonsillitis,   peritonsillar   abscess, 


54  SPECIFIC   INFECTIONS. 

and  Vincent's  angina  should  offer  but  slig-ht  difficulty  in 
dift'erentiation  from  diphtheria. 

The  resemblance' of  the  laryngitis  of  incipient  measles  to 
diphtheritic  croup  or  laryngeal  diphtheria  is  often  so  marked 
as  to  make  an  immediate  and  certain  diagnosis  impossible. 

In  cases  in  which  a  reasonable  suspicion  of  diphtheria 
exists  the  matter  of  diagnosis  will  be  simplified  by  the  use  of 
antitoxin  which  can  never  do  harm. 

TREATMENT. 

In  the  treatment  of  diphtheria  we  are  infinitely  better  sit- 
uated than  in  dealing  with  other  contagious  diseases,  because 
we  have  at  our  disposal  a  definite  physiologic  remedial  agent. 
Following"  the  researches  of  Behring,  an  antitoxin  for  diph- 
theria has  been  perfected,  which  in  practice  consists  of  the 
serum  of  the  horse  immunized  by  the  injection,  in  progressively 
increasing  doses,  of  diphtheria  toxins.  For  convenience  in 
description  and  administration,  a  unit  of  diphtheria  antitoxin 
has  been  established.  A  unit  is  that  quantity  of  antitoxin  "that 
will  just  neutralize  100  minimal  fatal  doses  of  toxin  for  a  250- 
gram  guinea-pig." 

The  action  of  the  antitoxin  may  be  described  as  tending 
to  the  production  of  passive  immunity.  It  does  not  primarily 
have  any  other  action  or  expected  effect  than  of  itself  to  neu- 
tralize the  toxins  produced  by  the  diphtheria  bacillus  within 
the  body  of  the  patient  either  before  or  after  the  use  of  the 
antitoxin,  and  to  aid  in  destroying  the  bacilli  themselves. 

The  antitoxin  is  administered  either  subcutaneously,  intra- 
muscularly or  intravenously.  While  to  the  experienced  oper- 
ator* intravenous  injection  is  easy,  it  is  a  procedure  of  suffi- 
cient difficulty  to  render  it  undesirable  as  a  routine  measure 
in  the  hands  of  the  occasional  user. 

I  prefer  the  intramuscular  injection,  believing  that  it  causes 
least  discomfort,  and  that  a  dose  thus  given  has  a  prompter 
and  more  efficacious  action  than  when  an  equal  or  larger  dose 
is  given  subcutaneously. 

The  syringe  and  needle  having  been  sterilized,  the  anti- 
toxin is  drawn  into  the  syringe  with  care.  Where  the  anti- 
toxin supplied  commercially  is  used  it  is  almost  always  within 


DIPHTHERIA.  55 

the  syringe  as  a  first  container.  The  point  of  election  for  the 
injection  is  the  anterior  external  surface  of  the  thigh.  The 
area  for  the  introduction  of  the  needle  is  prepared  by  the 
application  of  tincture  of  iodin.  The,  needle  is  thrust  well 
into  the  muscle,  and  if  the  injection  be  not  made  with  too 
great  rapidity  great  pain  is  not  caused.  After  the  withdrawal 
of  the  needle  the  opening  is  closed  by  the  use  of  a  small 
pledget  of  cotton  and  collodion. 

The  dosage  of  antitoxin  is  still  a  matter  of  opinion,  and  to 
a  certain  extent  must  always  remain  so.  It  must  be  deter- 
mined by : 

1.  The  location  and  severity  of  the  local  diphtheritic 
process. 

2.  The  patient's  general  condition. 

3.  The  patient's  age. 

4.  The  day  of  the  disease  upon  which  it  is  given. 

There  are  certain  factors,  in  our  estimation,  of  the  dosage 
which  render  it  impossible  to  fix  a  mathematically  correct 
dose.  Most  important  of  these  is  the  fact  that  we  cannot 
accurately  determine  the  virulence  of  a  particular  attack ;  in 
other  words,  express  definitely  the  amount  of  toxemia  we  have 
to  deal  with.  The  dosage,  therefore,  must  always  be  based 
upon  experience,  and  be,  to  a  certain  extent,  empirical. 

The  day  of  the  disease  is  of  importance  also ;  it  is  evident 
that  the  sooner  the^ antitoxin  is  given  the  less  will  be  needed. 
It  is  a  matter  of  common  experience  that  antitoxin  given 
after  the  third  day  is  much  less  efficacious,  and  must  be  given 
in  much  greater  doses.  We  must  bend  all  our  endeavors  to 
the  prompt  administration  of  antitoxin. 

The  age  of  the  patient  is  not  of  the  greatest  importance, 
except  in  infants.  Children  under  the  age  of  2  are  given 
about  one-half  the  dose  required  for  other  patients,  and  we 
rarely  give  less  than  5000  units,  except  to  infants. 

A  severe  infection  requires  a  larger  dose  than  a  mild  one, 
except  that  we  do  not  ever  reduce  our  dosage  below  a  certain 
working  minimum  sufficient  to  meet  the  probable  require- 
ments in  a  given  case. 

The  antitoxin  is  to  be  given  promptly,  and  in  sufficient 
dosage  to  abate  the  disease  quickly,  thus  ensuring  recovery 
^nd  lessening  the  incidence  of  complications  or  sequelae.     It 


56  SPECIFIC   INFECTIONS. 

is,  therefore,  desirable  to  give  sufficient  antitoxin  at  the  first 
ijijcction  to  meet  the  needs  of  the  patient.  Generally,  if  the 
antitoxin  be  administered  early  this  can  be  accomplished.  But 
if,  within  twelve  to  eig-hteen  hours,  the  membrane  appears  to 
be  spreading,  a  second  dose  should  be  given. 

The  beneficial  action  of  the  antitoxin  manifests  itself 
clearly.  It  is  evidenced  by  the  improvement  in  the  patient's 
general  condition,  by  lessening  of  the  evidences  of  toxemia, 
and  by  a  prompt  improvement  in  the  local  lesions  of  the  dis- 
ease. The  membrane,  wherever  situated,  within  a  few  hours 
shows,  first,  a  cessation  of  its  spread,  if  this  has  still  been 
active ;  and,  secondly,  marked  evidences  of  separation  of  the 
membrane  already  present,  and  soon,  signs  of  healing  beneath. 

As  has  been  stated,  the  dosage  of  diphtheria  antitoxin  must 
be  such  that  a  very  prompt  improvement  is  noted  in  almost 
every  instance. 

In  general  terms,  it  may  be  formulated  thus : 

In  tonsillar  cases,  those  in  which  the  membrane  is  strictly 
limited  here,  the  dosage  on  the  first  day  is  50CX)  units.  On 
the  second  day  the  initial  dosage  would  be  10,000  to  20,000 
units,  while  after  the  second  day  from  20,000  to  40,000  units, 
and  even  more  would  be  given  as  an  initial  dose.  In  faucial 
diphtheria  about  the  same  dosage  holds  good. 

In  laryngeal  diphtheria,  when  there  is  no  dyspnea,  the 
initial  dosage,  if  the  case  is  seen  on  the  first  day,  should  be 
10,000  units,  or  if  there  is  the  least  sign  of  dyspnea,  15,000 
units.  If  seen  first  upon  the  second  day  such  a  case  should 
receive  at  least  from  15,000  to  20,000  units,  and  if  seen  later 
than  the  second  day  20,000  or  more  units  should  be  given. 

Nasal  cases  are  really  of  two  distinct  varieties,  and  this 
influences  our  treatment  also.  Where  there  is  but  slight 
moisture  from  the  nares,  and  the  diagnosis  is  made  by  culture 
only,  the  initial  dose,  if  the  case  is  seen  on  the  first  day,  should 
be  10,000  units,  the  dosage  again  increasing  as  the  case  is  seen 
later  in  the  disease. 

If,  however,  there  is  a  distinct  nasal  membrane,  with  dis- 
charge and  any  sign  of  toxemia,  20,000  units  should  be  given 
as  an  initial  dose,  if  the  patient  is  seen  on  the  first  day,  this 
first  dosage  going  as  high  as  30,000  to  50,000  units  if  the 


DIPHTHERIA.  57 

patient  is  given  his  first  dose  of  antitoxin  as  late  as  the  third 
day. 

The  maximum  total  dosage  that  may  be  given  to  a  patient 
in  the  course  of  the  disease  is  limited  more  by  our  difficulty 
in  procuring  for  a  given  case  as  much  antitoxin  as  seems 
desirable  than  by  any  ill  effects  from  large  doses.  Three  hun- 
dred thousand  units,  with  recovery,  have  been  given  in  a 
single  case. 

The  complications  in  the  use  of  antitoxin  are  rarely  of 
moment,  and  in  any  case  not  the  result  of  the  antitoxic  sub- 
stances, but  rather  of  the  vehicle,  the  horse  serum  itself. 

Abscess  following  correct  use  ^f  sterile  serum  is  rare, 
although  a  pressure  decomposition  has  been  known  to  occur 
where  very  large  quantities  of  the  antitoxin  have  been  used. 
This  occurrence  is  extremely  rare  with  the  intramuscular  use 
of  the  antitoxin.  Pain  and  tenderness  following  the  injection 
are  usually  of  no  great  moment,  especially  with  the  intramus- 
cular method  of  administration. 

If  an  abscess  occur,  incision  and  drainag'e  are  indicated. 
Simple  transient  induration,  if  annoying,  will  usually  yield  to 
hot  fomentations  or  poultices. 

Serum  sickness  is  a  term  applied  to  that  series  of  phe- 
nomena which,  in  susceptible  individuals,  follows  the  injection 
of  a  serum  {i.e.,  a  foreign  protein).  It  manifests  itself  as  an 
urticarial,  morbilliform,  or  scarlatinaform  rash,  accompanied 
at  times  by  fever,  nausea,  vomiting,  joint  pains,  edema  of  face 
and  joints,  and  general  malaise.  In  slight  forms  it  is  not 
uncommon  after  the  use  of  diphtheria  antitoxin,  even  in  the 
smaller  doses,  many  individuals  being  verv  susceptible.  It 
requires  no  special  treatment  and  is  self-limited. 

Anaphylaxis  is  a  subject  of  greater  importance,  although 
not  entitled  to  that  prominence  in  the  discussion  of  the  use 
of  diphtheria  antitoxin  which  has  often  been  given  it.  It  may 
be  defined  (Rosenau)  as  "a  condition  of  unusual  or  exagger- 
ated susceptibility  of  the  organism  to  foreign  proteins."  It 
is  called  forth  by  the  administration  of  a  second  dose,  as  of 
serum,  when  the  patient  has  been  rendered  sensitive  by  a 
first  dose.  In  its  milder  forms  it  resembles  serum-sickness. 
Graver  forms,  even  ending  in  collapse  and  death,  have  been 
reported,  but  in  human  beings  it  is  an  occurrence  of  such 


58  SPECIFIC    INFECTIONS. 

rarity  that  it  may  be  left  entirely  out  of  consideration  in  the 
use  of  antitoxin.  The  danger  is  so  slight  and  the  antitoxin 
so  necessary  that  there  should  be  no  hesitation  in  its  use  when 
indicated. 

The  prophylactic  use  of  diphtheria  antitoxin  is  well  estab- 
lished, and  in  it  there  is  a  field  of  great  usefulness.  The  aver- 
age prophylactic  dose  is  1500  units.  The  protection  therefrom 
is,  however,  not  of  very  great  duration,  sometimes  as  short 
as  ten  days.  The  fact  that  we  have  at  our  command  a  specific 
antitoxin  for  diphtheria  should  not  lead  us  to  overlook  the 
importance  of  the  general  medical  and  systemic  treatment  of 
the  disease. 

Since  we  know  the  infectious  agent,  we  must,  in  addition 
to  enforcing  the  rules  for  quarantine  and  isolation,  just  as 
described  in  the  treatment  of  scarlet  fever,  be  especially  on 
our  guard  to  avoid  any  semblance  of  carelessness  after  contact 
with  a  patient  or  with  infectious  material.  It  is  probable  that 
diphtheria  is  carried  from  one  patient  to  another  by  means 
that  are  entirely  avoidable. 

The  general  hygienic  and  medical  treatm.ent  of  diphtheria 
offers  but  few  difficulties.  The  room,  preferably  large,  airy 
and  well  ventilated,  should  be  kept  at  a  temperature  of  about 
65°  F.  (18.3°  C).  The  patient  may  receive  a  daily  tepid  bath 
if  there  is  no  contraindication.  This  must  be  given  in  bed,  so 
that  it  involves  no  exertion  on  the  part  of  the  patient.  A 
cardiac  derangement  of  any  moment  may  make  it  undesirable 
or  dangerous  even  to  move  a  patient  sufficiently  to  give  him 
a  full  bath  on  any  one  day. 

In  the  acute  stage  of  diphtheria  liquid  diet  is  indicated, 
and  this  should  be  continued  for  three  or  four  days  after  the 
local  diphtheritic  process  is  well.  After  this  period  the  diet 
may  be  cautiously  increased  by  the  addition  of  stewed  fruits, 
gelatins,  puddings,  gruels  and  well-prepared  cereals.  Full  diet 
may  be  given  after  convalescence  is  well  established  and  the 
kidneys  normal. 

Difficulties  in  feeding  diphtheria  patients  may  arise  when 
there  is  paralysis  of  the  pharyngeal  muscles.  When  this  ren- 
ders swallowing  impossible,  nasal  feeding  must  be  resorted  to. 

Water  should  be  given  freely  in  diphtheria,  not  only  be- 
cause of  the  fever  present,  but  also  to  minimize  the  tendency 
to  nephritis. 


DIPHTHERIA.  59 

The  bowels  must  be  kept  open.  In  infants  castor  oil 
should  be  given;  in  older  patients  salines,  citrated  magnesia 
or  other  laxatives  may  be  substituted.  Particularly  when 
there  is  a  cardiac  complication  must  things  be  so  managed 
that  there  is  no  straining  at  stool,  as  this  may  cause  severe, 
and  even  fatal  collapse.  Purging  should  be  avoided  at  all 
times. 

The  diphtheria  patient  should  be  kept  in  bed  in  the  mildest 
of  cases  for  at  least  three  weeks,  and  from  five  weeks  upward 
when  there  is  any  demonstrable  cardiac  or  nervous  involve- 
ment. 

The  management  of  cases  of  laryngeal  diphtheria  presents 
a  problem  somewhat  different  from  that  of  a  simple  pharyn- 
geal one.  In  the  former  we  have  to  treat  not  only  an  intoxica- 
tion, but  also  a  mechanical  obstruction  to  breathing,  with 
possible  asphyxiation. 

It  often  seems  that  by  keeping  the  patient  somewhat 
warmer  than  in  other  cases,  and  by  the  use  of  steam  by  the 
croup-kettle  and  cover,  if  free  access  of  air  be  allowed  the 
patient,  we  can  accomplish  something  to  make  breathing 
easier. 

In  the  use  of  steam  in  laryngeal  diphtheria  care  should  be 
taken  not  to  employ  it  to  the  exclusion  of  the  air.  A  simple 
canopy,  with  the  spout  of  the  croup-kettle  so  situated  as  to 
allow  the  steam  to  flow  toward  the  patient's  head,  will  be 
sufficient.  Oftentimes  the  patient  will  show  evidence  of  the 
relief 'afforded  by  placing  the  head  directl}^  in  the  path  of  the 
current  of  steam. 

For  the  treatment  of  the  dyspnea  of  laryngeal  diphtheria 
1  have  always  found  the  application  of  turpentine  stupes  to 
the  neck  and  upper  chest  to  be  of  decided  advantage.  This  is 
evidenced  by  the  fact  that  adults  and  older  children  will  very 
often  express  a  feeling  of  relief  as  soon  as  the  application  has 
been  made.  There  are  several  methods  of  applying  stupes. 
Ol.  terebenthinse,  2  fluidrams  (/.?  mils)  ;  ol.  olivre,  1  fiuidram 
(3.75  mils),  in  hot  water,  2  pints  (11.),  should  be  pre- 
pared in  a  2-quart  pitcher,  and  tlien  poured  into  r.  basin  as 
needed.  A  piece  of  flannel  one-half  yard  square  should  be 
wrung  out  of  this  solution,  fluft'ed,  tested  as  to  heat,  and  then 
snugly  applied  to  the  larynx  and  upper  chest.    This  should  be 


60  SPECIFIC    INFECTIONS. 

changed  every  few  Aiinutes,  the  idea  being  to  have  the  flannel 
always  as  warm  as  comfort  will  permit.  As  an  emergency 
measure,  the  thorough  rubbing  of  the  larynx  and  chest  with 
camphorated  oil,  and  the  subsequent  application  of  the  hot 
flannel,  will  do  good.  The  heating  of  the  flannel  on  the 
chimney  of  an  ordinary  coal-oil  lamp  will  oftentimes  furnish 
sufficient  heat  when  hot  water  is  not  immediately  available. 

The  internal  administration  of  ammonium  carbonate  and 
syrup  of  ipecac  is  supposed  to  be  of  advantage  in  hastening 
separation  of  the  membrane.  Should  these  measures  be  of  no 
avail,  then  operative  interference  must  be  resorted  to  in  the 
form  of  intubation  or  tracheotomy. 

The  indications  for  operative  interference  are  well-marked 
dyspnea,  with  recession  of  the  soft  parts  of  the  chest,  restless- 
ness, and  a  weak,  rapid  pulse,  especially  if  these  symptoms  do 
not  show  signs  of  abating  after  the  serum  and  other  treatment 
have  been  administered. 

The  greatest  of  care  should  be  exercised  always  in  deter- 
mining when  the  time  for  operative  interference  has  arrived. 
Operation  should  not  be  done  too  early.  The  manipulation, 
with  its  resultant  damage  to  the  soft  parts,  and  the  presence 
of  the  tube,  which  acts  as  a  foreign  body,  may  add  to  the 
dangers  of  an  already  dangerous  situation,  and  should  be 
avoided  whenever  possible.  At  the  same  time  the  too-long 
delay  in  interfering,  with  a  too-great  loss  of  strength,  may 
leave  the  patient  unable  to  do  his  part,  even  after  an  other- 
wise most  successful  operation. 

Intubation  is  the  operation  of  choice  in  institutions,  or 
where  trained  attendants  are  close  at  hand.  Tracheotomy  is, 
broadly  speaking,  to  be  preferred  in  general  practise. 

Intubation.  This  should  be  done  always  with  the  patient 
in  the  recumbent  posture.  With  the  hands  by  the  sides,  the 
patient  is  rolled  and  pinned  securely  in  a  sheet.  The  head  is 
then  thrown  back  by  having  the  neck  and  shoulders  rest  upon 
a  pillow  or  rolled  blanket.  An  assistant  sitting  at  the  head 
of  the  bed  or  table  holds  the  head  of  the  patient,  at  the  same 
time  keeping  the  mouth-gag  in  position  on  the  left  side  of  the 
patient's  mouth.  The  operator  then  passes  very  gently  his 
left  index  finger  along  the  tongue  to  its  base,  where  the  epi- 
glottis is  found  and  turned  backward,  the  finger  then  entering 


DIPHTHERIA.  61 

the  larynx  and  resting  upon  its  posterior  wall,  care  being 
taken  not  to  cause  obstruction  to  the  intake  of  air.  The 
operator  with  his  hand  then  passes  the  tube  back  until  its 
point  comes  in  contact  with  the  left  index  finger.  Then,  with 
the  finger  as  a  guide,  the  end  of  the  tube  is  engaged  in  the 
larynx,  the  handle  of  the  introducer  is  slightly  raised,  and  the 
tube  allowed  to  drop  in  with  very  little  pressure.  The  tube 
is  then  disengaged  from  the  obturator  and  allowed  to  remain. 
The  string,  or  what  is  much  better,  a  No.  4  banjo  wire, 
securely  looped  in  the  hole  in  the  head  of  the  tube,  should  be 
allowed  to  remain  in  place,  and  attached  on  the  outside  of 
patient's  cheek  by  means  of  a  piece  of  adhesive  plaster.  The 
string,  or  wire,  should  be  drawn  fairly  taut  for  fear  of  extu- 
bation  with  the  tongue.  As  a  further  means  of  preventing 
removal  of  the  tube  by  the  patient,  the  movements  of  the 
elbows  should  be  prevented  by  applying  light  splints  to  the 
entire  arm.  The  tube  should  be  taken  out  three  or  four  days 
after  introduction,  especially  if  the  temperature  and  respira- 
tion be  normal. 

When  the  tube  is  anchored,  as  mentioned  above,  extuba- 
tion  is  a  most  simple  procedure,  infinitely  so  when  compared 
with  that  in  which  the  regular  instrument  or  extubator  is 
used.  By  making  taut  the  string,  or  wire,  Avith  the  fingers 
of  one  hand,  and  rapidly  passing  the  index  finger  of  the  other 
hand  along  the  string  to  the  larynx,  the  tube  can  be  lifted 
out  in  a  few  seconds,  and  with  practically  no  disturbance  to 
the  patient.  This  method  possesses  all  advantages  over  the 
old  one  with  the  extubator;  principally  it  does  awa}^  with  the 
manipulation  which  the  use  of  the  extubator  entails,  and  also 
the  removal  of  the  element  of  nervousness,  which  is  quite  a 
feature  in  some  cases.  In  removing  an  anchored  tube  it  is  not 
necessai-y  even  to  take  the  child  from  its  bed,  and  very  often 
it  can  be  done  during  sleep,  and  without  the  child's  knowledge. 

In  removing  the  tube  it  is  well  to  give  consideration  to  the 
hour  and  the  day ;  a  sunny  day  is  to  be  preferred,  and  an  early 
hour  in  the  forenoon,  as  it  is  at  nig"ht  that  respiratory  difti- 
culties  are  more  prone  to  develop.  In  some  cases,  that  is 
those  that  do  not  appear  favoral)le  after  extubation,  it  is  worth 
while  to  use  steam  and  stupes,  as  already  described  in  our 
efforts  to  overcome  the  dyspnea.     A  return  of  the  dyspnea 


62  SPECIFIC   INFECTIONS. 

may  require  a  reintubation.  The  tube  should  then  be  re- 
moved, after  three  or  four  days  more.  In  all  cases  of  intuba- 
tion the  utmost  gentleness  should  be  observed  to  prevent 
damage  to  the  soft  parts.  After  intubation  the  foot  of  the 
bed  should  be  elevated  to  facilitate  drainage,  and  thereby  to 
lessen  the  chances  of  pneumonia. 

As  said  before,  intubations  should  be  done  only  after  every 
effort  has  been  put  forth  to  avoid  it.  A  tube  in  the  larynx 
acts  as  a  foreign  body,  causing  increased  and  retained  secre- 
tions, and  in  some  instances  ulceration.  Should  the  child, 
after  repeated  efforts,  be  unable  to  do  without  the  tube,  then 
a  specialist  should  be  called  in ;  what  is  better  would  be  to 
send  the  child  to  the  specialist  after  release  from  quarantine. 
In  the  handling  of  tube  cases  special  efforts  should  be  directed 
towards  securing  a  large,  sunny,  airy  and  warm  room. 

Tracheotomy.  The  technic  for  the  operation  of  trache- 
otomy for  the  relief  of  laryngeal  stenosis  in  diphtheria  is  the 
same  as  is  that  for  any  other  similar  condition.  Ether  anes- 
thesia is  used,  save  in  emergency  cases,  in  which  an  anesthetic 
will  not  be  necessary.  The  operator  must  be  sure  to  make  the 
incision  sufficiently  long,  say  1^  to  2  inches  (4  to  5  cm.),  and  to 
divide  two  or  three  of  the  rings  of  the  trachea.  He  should 
not  be  in  too  great  a  hurry  to  insert  the  tube,  but  should  hold 
open  the  wound  with  dilators,  or  with  the  handle  of  the  knife 
held  at  right  angles  to  the  incision,  until  the  breathing  is  tran- 
quil and  easy.  In  the  meantime,  he  should  search  for  pieces 
of  membrane,  and,  should  any  be  found,  should  remove  them 
with  forceps.  The  tube  should  then  be  inserted.  If  there  be 
much  mucous  or  hemorrhage,  the  foot  of  the  bed  or  table 
should  be  elevated  to  facilitate  drainage  from  the  larynx  and 
trachea.  A  simple  dressing  of  sterile  gauze  is  placed  around 
the  tube  and  over  the  wound,  and  is  protected  from  the  secre- 
tions of  the  wound  by  a  flap  of  rubber  tissue. 

If  the  breathing  be  disturbed,  as  will  be  the  case  in  certain 
instances,  because  of  dried  mucus  plugging  the  opening  of 
the  tube,  the  removal  of  the  inner  tube  and  its  cleansing  will 
be  all  that  is  required.  As  long  as  the  breathing  is  without 
embarrassment  the  tube  should  not  be  disturbed.  The  chang- 
ing of  the  dressing  once  or  twice  in  twenty-four  hours  will  be 
all-sufficient. 


DIPHTHERIA.  .63 

If  a  warm  room  be  obtainable,  steam  will  not  be  required. 
If  this  cannot  be  had,  then  steam,  as  from  the  croup-kettle, 
and  so  placed  that  the  air  currents  will  carry  the  vapor 
towards  the  patient,  will  be  sufficient  to  moisten  and  warm 
the  room. 

A  good  sign  in  these  cases  is  a  return  of  the  temperature 
to  normal,  and  a  lessening  in  the  respiration  rate.  This  means 
that  the  patient  has  escaped  bronchopneumonia,  which  is  the 
complication  most  to  be  dreaded.  A  bad  sign  is  a  profuse 
discharge  of  thick,  tenacious  mucus. 

After  allowing  sufficient  time  for  the  separation  of  the 
membrane,  and  for  the  subsidence  of  inflammation,  an  attempt 
should  be  made  to  remove  the  tube  by  plugging  the  opening. 
If  the  patient  then  be  able  to  breathe  well,  the  tube  may  be 
removed,  and  the  wound  covered  with  a  plain  gauze  dressing. 
Sometimes  the  tube  may  remain  in  for  days,  weeks,  or  months 
even.  In  some  instances  nervousness  will  prevent  the  child 
from  being  able  to  do  without  the  tube.  In  such  cases  the 
idea  is  to  use  a  closed  tube  or  dummy  sufficiently  larg"e  to  till 
the  wound  or  opening,  but  not  of  sufficient  length  to  reach 
into  the  trachea.  Should  the  case  promise  to  be  a  chronic 
tube-wearer,  then  a  specialist,  as  above  mentioned,  should  be 
consulted. 

The  complications  of  diphtheria  most  important  as  con- 
cerns frequency  and  gravity  are  cardiac  failure,  the  paralyses 
and  bronchopneumonia. 

The  treatment  of  cardiac  failure  in  diphtheria  does  not 
vary,  whether  this  condition  be  early  or  late,  or  whether  it 
be  considered  primarily  myocardial  or  nervous  in  origin.  The 
use  of  alcohol  and  strychnin  as  a  routine  may  serve  to  pre- 
vent heart  failure.  When,  however,  it  occurs,  the  means  at 
hand  for  its  treatment,  while  not  limited  in  number,  are  all  of 
doubtful  efficacy. 

The  patient  must  be  kept  absolutely  at  rest,  and  even  the 
slightest  movement  requiring  exertion  must  be  avoided.  If 
the  patient  be  not  in  a  state  of  collapse,  the  use  of  such  stim- 
ulants to  the  heart  as  atropin  and  caffein  may  steady  and 
strengthen  the  heart-beat,  and  avert  the  danger  threatened.  If 
the  patient  be  in  collapse,  these  are  also  the  drugs  of  choice. 
Digitalis  should  never  be  given.     Very  small  doses  of  mor- 


64  SPECIFIC   INFECTIONS. 

phin  may  be  of  aid,  in  conjunction  with  the  cardiac  stimu- 
lants, and  help  to  keep  the  patient  quiet.  If  vomiting  accom- 
panies the  collapse,  feeding  by  mouth  must  be  stopped,  and 
rectal  feeding  instituted.  Iced  champagne  will  sometimes  be 
retained,  and  will  help  as  a  stimulant  if  the  stomach  toler- 
ates it. 

In  connection  with  cardiac  failure  we  must  bear  in  mind 
that,  whereas  its  prognosis  is  almost  always  fatal,  yet  its 
prevention  is  easy.  The  early  administration  of  sufficient 
antitoxin  will  prevent  the  toxemia  that  causes  both  the  myo- 
carditis and  the  nerve  degeneration  giving  rise  to  heart  failure 
in  diphtheria. 

This  having  been  done,  we  have  but  to  keep  the  patient 
quiet,  to  see  that  he  avoids  exertion,  even  the  very  slightest, 
and  as  a  routine  give  small  doses  of  strychnin,  %o  grain 
(0.001  Gm.),  every  fourth  hour,  to  an  adult,  and  alcohol  well 
diluted,  from  1  fluidrachm  (3.75  mils),  for  a  child  of  4  years, 
to  ^  fluidounce  (15  mils)  for  an  adult  every  fourth  hour. 

Bronchopneumonia  is  one  of  the  very  frequent  causes  of 
death  in  diphtheria.  It  occurs  principally  in  cases  of  the 
laryngeal  type,  and  more  particularly  in  those  that  have  been 
the  subjects  of  intubation  or  tracheotomy.  Beyond  the  secur- 
ing of  a  large,  warm,  sunny  and  airy  room,  there  is  nothing 
more  needed  than  would  be  for  cases  of  bronchopneumonia 
developing  from  other  causes.  In  some  cases  I  have  employed 
bacterins,  and  with  apparently  good  results  in  a  few  instances. 
I  regret  that  I  cannot  speak  more  positively  concerning  this. 

Post  diphtheritic  paralysis,  due  to  nerve  degeneration  caused 
by  the  toxemia,  generally  comes  on  after  the  second  week  of 
diphtheria.  Just  as  practically  every  ill  effect  of  diphtheritic 
toxemia  may  be  avoided  by  the  correct  and  early  use  of  the 
antitoxin,  so  may  the  palsies  be  kept  but  part  of  the  symptom 
syndrome. 

The  soft  palate  is  most  frequently  the  site  of  palsy,  which 
supervenes  comparatively  early.  It  makes  itself  evident  by 
difficulty  in  swallowing,  by  regurgitation  of  fluids  through  the 
nose,  and  by  a  nasal  twang  to  the  voice. 

Paralyses  of  the  extremities,  eye  muscles,  sphincters  and 
respiratory  muscles  also  occur.  If  the  last-named  condition 
be  severe,  death  will  result. 


ERYSIPELAS.  65 

In  severe  cases  of  palatal  palsy,  nasal  feeding-  is  called  for 
until  function  is  restored. 

There  is,  except  prevention,  no  effectual  treatment  for  post 
diphtheritic  paralyses.  Unless,  as  in  cardiac  failure  and  the 
very  g^rave  respiratory  palsies,  death  occurs,  spontaneous  re- 
covery is  the  rule.  No  form  of  medicinal  or  electric  stimula- 
tion has  ever  affected  the  course  of  these  conditions,  in  my 
experience. 

The  nephritis  of  diphtheria  rarely  takes  a  severe  course, 
and  beyond  the  free  use  of  potassium  citrate,  correct  diet,  and 
the  careful  use  of  laxatives,  little  is  required.  Uremia  after 
diphtheritic  renal  conditions  is  very  rare. 

In  mixed  infections  of  diphtheritic  sore  throat,  cervical 
adenitis  sometimes  occurs.  The  use  of  hot  fomentations  will 
either  abort  them  or  render  the  glands  fit  to  be  opened. 

As  far  as  the  membrane  of  the  diphtheritic  process  itself 
is  concerned,  I  advise  the  use  of  no  local  treatment,  with  the 
exception  of  a  mild  gargle  for  adults  and  larger  children. 

The  treatment  of  carriers  or  convalescents  ready  for  dis- 
charge, except  for  persistent  positive  cultures,  is  one  of  the 
most  annoying  problems  connected  with  the  management  of 
diphtheria.  All  manner  of  germicides  and  antiseptics  have 
been  tried,  and  with  indifferent  results.  The  excision  of  dis- 
eased or  enlarged  tonsils  will  be  found  of  decided  advantage 
in  almost  all  cases.  The  removal  of  adenoids  in  nasal  cases 
may  prove  of  service.  Care  should  be  taken,  however,  not  to 
undertake  operation  until  all  danger  of  heart  or  nervous  com- 
plications shall  have  passed. 

Diphtheria  cases  may  be  considered  well,  and  fit  to  dis- 
charge, when  all  local  evidences  of  the  disease  shall  have  dis- 
appeared, and  when  at  least  two  successive  negative  cultures 
on  successive  days  shall  have  been  obtained.  The  physician 
must  be  guided  by  the  quarantine  regulations  of  his  own 
locality. 

ERYSIPELAS. 

This  condition  is,  in  reality,  an  infection  by  a  strepto- 
coccus— the  Streptococcus  erysipclatis.  Because  of  the  pecul- 
iar characteristics  of  the  symptoms,  and,  again,  because  of  its 

5 


66  SPECIFIC    INFECTIONS. 

frequent  localization  to  the  face,  it  is  customary  to  describe 
this  form  and  to  treat  it  as  a  distinct  entity. 

There  is  always  a  portal  of  entry,  frequently  a  mere  abra- 
sion, which  is  frequently  so  inconspicuous  as  to  attract  no 
notice.  The  first  symptoms  are  chill,  high  fever,  the  appear- 
ance of  a  red  area  somewhere  over  the  surface  of  the  body, 
with,  subsequently,  a  rapid  spreading  of  this  area.  The 
affected  part  is  red,  swollen,  indurated  and  painful.  The 
edges  of  the  erysipelatous  area  are  sharply  marked  off  by  a 
ridge  of  indurated  skin  contrasting  markedly  with  a  healthy 
white  skin  on  the  edges. 

Soon  the  surface  of  the  skin  is  covered  with  blebs  of  vary- 
ing size,  filled  with  clear  serum.  These  blebs  later  rupture 
and  the  surface  becomes  covered  with  a  crust.  Occasionally 
there  is  suppuration  of  the  underlying  connective  tissue.  The 
mucous  membranes  may  be  affected;  occasionally,  meningitis 
occurs.     The  writer  has  seen  two  such  cases. 

The  fever  rises  rapidly,  often  reaching  a  point  between 
103°  and  105°  F.  (39.4°  and  40.5°  C). 

The  action  of  the  heart  is  rapid,  the  pulse  full  and  bound- 
ing.   Often  the  patient  is  delirious. 

Facial  erysipelas  often  begins  with  the  infecting  area  on 
the  bridge  of  the  nose,  both  cheeks  are  rapidly  implicated,  and 
very  soon  the  whole  face  is  swollen,  the  eyes  are  closed,  and 
the  ears  stand  out  as  swollen  red  excrescences  on  the  side  of 
the  head.  The  scalp  and  neck  are  often  affected.  The  lesion 
on  the  face  can  scarcely  be  mistaken  for  any  other  condition. 
On  the  limbs  and  about  the  joints  collections  of  pus  may, 
unfortunately,  be  mistaken  for  erysipelas.  The  differentiation 
may  be  made  by  careful  observation  that  the  skin  is  not 
affected  alone,  but  that  the  underlying  tissues  are  likewise 
involved.  Fluctuation  is  present  in  suppuration.  It  is  rarely 
present  in  cases  of  erysipelas,  and  never  appears  early. 

Erysipelas  is  transmissible  from  one  individual  to  another, 
and  the  early  institution  of  prophylactic  measures  are  essen- 
tial. All  discharges  should  be  collected  on  material  which  can 
be  immediately  destroyed  by  burning.  The  hands  should  be 
thoroughly  cleansed  and  disinfected  immediately  upon  hand- 
ling the  case.  Because  this  particular  type  of  streptococci  is 
peculiarly  liable  to  become  implanted  in  wounds  and  on  the 


ERYSIPELAS.  67 

genital  mucous  membranes,  it  is  highly  important  for  the 
physician  to  refuse  to  attend  cases  of  labor  while  he  is  attend- 
ing a  case  of  erysipelas.  If  circumstances  make  it  imperative, 
however,  that  both  sorts  of  patients  be  attended  at  one  time, 
it  is  necessary  that  the  physician  should  use  gloves  while 
handling  the  erysipelas  case ;  that  before  attending  a  labor 
case  the  physician  should  change  his  clothing,  take  a  full  bath, 
carefully  disinfect  his  hands  before  going  to  the  bedside,  and 
use  sterile  rubber  gloves  while  in  attendance  on  the  lying-in 
woman.  These  precautions  will  probably  make  the  labor  case 
safe. 

TREATMENT. 

Local  treatment  is  of  use.  The  number  of  applications 
which  have  been  suggested  is  almost  beyond  computing, 
showing  that  there  is  no  application  which  is  curative,  though 
several  are  useful.  Ordinary  cold  water  applied  by  com- 
presses gives  comfort,  but  it  does  not  limit  the  inflammation. 

A  saturated  solution  of  magnesium  sulphate  is  of  value. 
It  gives  the  same  relief  as  the  water,  and,  I  believe,  limits  to 
a  certain  extent  the  extension  of  the  inflammation. 

Lead-water  and  laudanum  are  of  value  in  giving  relief  to 
the  burning  and,  perhaps,  limit  the  inflammation. 

Ichthyol  has  been  used  by  the  author  with  no  more  suc- 
cess than  salt  solution,  magnesium  sulphate,  or  simple  water. 
It  is  dirty,  smells  badly,  and  is  scarcely  worth  the  money 
spent  on  it. 

The  edges  of  the  inflammation  and  the  sound  skin  have 
been  painted  with  full-strength  tincture  of  iodin,  with  seem- 
ing good  results.  Phenol  has  been  injected  along  the  advanc- 
ing edge  of  the  eruption,  and  good  results  are  claimed  for  it. 

In  making  use  of  any  of  the  topical  applications,  it  is  well 
to  keep  the  entire  infected  surface  protected  from  the  air. 

There  is  no  specific  treatment  for  erysipelas.  Restlessness 
and  delirium  may  be  controlled  by  full  doses  of  bromid  of 
potassium,  30  grains  (1.95  Gms.)  every  two  hours,  and  then 
in  lesser  quantities.  This  may  be  reinforced  by  the  use  of 
morphin  and  hyocin  hypodermically. 

Tincture  of  chlorid  of  iron  has  been  used  for  years  in  30- 
drop  (1.8  mils)  doses,  well  diluted,  every  three  hours.     It  is 


68  SPECIFIC   INFECTIOXS. 

irritating  to  the  stomach,  and  this  complication  must  be 
looked  out  for.  Some  practitioners  give  it  in  connection  with 
quinin.  The  author  has  rarely  used  quinin,  and  has  not 
seen  particularly  good  effects  when  he  has.  Alcohol  may  be 
used  in  small  quantities  as  a  food. 

Food  is  important,  milk  reinforced  with  cream  and  sugar, 
in  the  form  of  junket,  with  cornstarch  or  other  carbohydrates 
being  useful.  Large  quantities  of  water  should  be  given  to 
lessen  the  toxemia. 

The  heart  must  be  sustained  with  digitalis,  strychnin  and 
caft'ein,  as  in  other  septic  conditions.  The  temperature  may 
be  controlled  by  sponging  or  by  tubbing.  As  the  duration  of 
the  illness  is  relativel}^  short,  this  antipyretic  treatment  is  not 
as  necessary  as  in  long-continued  sepsis. 


TUBERCULOSIS. 

The  several  types  of  tuberculosis,  which  will  be  considered 
here,  are  general  or  miliary  tuberculosis,  tuberculosis  of  the 
joints,  tuberculosis  of  the  peritoneum,  tuberculosis  of  the 
genito-urinar}^  organs,  tuberculosis  of  the  glands  and  tuber- 
culosis of  the  nervous  system. 

The  general  treatment  of  all  these  conditions  must  be 
much  the  same — rest,  an  abundance  of  fresh  air,  and  an 
abundance  of  food  are  necessary  to  combat  the  tuberculous 
tendency,  whether  the  disease  is  to  eventuate  in  a  general 
tuberculosis,  a  tuberculosis  of  the  lungs,  or  a  tuberculosis  of 
one  of  the  other  organs. 

It  is  a  well-known  fact  that  tuberculosis  general!}^  is 
acquired  at  a  ver)^  early  age,  and  therefore,  one  of  the  first 
duties  of  parents  and  guardians  of  children  is  to  see  that  they 
are  not  exposed  to  tuberculous  infection  any  more  than  pos- 
sible. If  the  3-oung  of  to-day  were  allowed  to  have  more  fresh 
air  in  their  sleeping  rooms,  were  encouraged  to  live  more  in 
the  open,  were  not  taught  to  be  afraid  of  catching  cold — were 
taught  that  if  they  are  exposed  to  extremes  of  temperature 
their  body  should  be  clothed,  so  that  thev  would  not  be  chilled 
and  open  themselves  to  the  development  of  anv  infection,  in- 
cluding tuberculosis,  there  certainly  would   not  be   so  many 


TUBERCULOSIS.  69 

cases  of  tuberculosis  of  the  lungs,  and  of  the  various  other 
organs  in  later  life,  according  to  the  statistics  shown. 

General  Miliary  Tuberculosis.  This  generalized  tuberculosis 
occurs  in  two  forms,  the  typhoid  and  the  meningitic. 

In  the  typhoid  form  the  disease  has  many  of  the  charac- 
teristics of  typhoid  fever.  Certain  differences  marked  are 
noted  between  the  clinical  pictures  of  the  two  infections.  The 
patient  evidences  malaise,  becomes  the  subject  of  fever,  which 
in  the  very  beginning  is  usually  much  more  irregular,  and 
may  be  more  intermittent,  than  in  typhoid  fever.  The  pulse, 
too,  has  a  certain  irregularity,  sometimes  slow,  sometimes 
fast,  which  is  not  characteristic  of  typhoid  fever.  The  intes- 
tinal disturbances  are  not  so  common  in  general  tuberculosis 
as  they  are  in  typhoid  fever,  diarrhea  being  rare,  rather  than 
the  rule. 

The  patient  also  emaciates  much  more  rapidly  than  is  the 
ordinary  rule  in  typhoid  fever. 

Examination  of  the  blood  is  of  the  greatest  value.  In 
typhoid  fever  there  is  a  positive  Widal  reaction.  In  typhoid 
forms  of  tuberculosis  the  Widal  reaction  is  wanting.  There 
is  the  same  leucopenia  in  both  cases.  Headache  is  not  so 
severe  in  tuberculosis  as  it  is  in  typhoid  fever.  Often  after  a 
week  or  two  the  lungs  become  the  seat  of  miliary  tubercles, 
and  these  begin  to  give  the  symptoms  of  general  irritation  of 
the  chest.  It  is  a  sort  of  granular  breathing,  and  a  general 
bronchitis  rather  than  the  sign  of  any  actual  consolidation. 

Careful  examination  of  the  eyes  by  an  expert  may  show 
tubercles  in  the  choroid.  Spinal  puncture  may  show  tubercle 
bacilli  in  the  spinal  fluid ;  more  commonly  the  cytologic  for- 
mula shows  high  lymphocytosis. 

The  treatment  of  this  universally  fatal  form  of  tuberculosis 
is  necessarily  without  value,  so  far  as  saving  the  patient's  life 
is  concerned.  Much  can  be  done,  however,  to  make  the 
patient  comfortable.  The  temperature  can  be  controlled  by 
sponging  or  by  bathing;  headache  may  be  relieved  b}'  the  use 
of  opiates,  the  bromids  and  chloral,  care  being  taken  that  the 
individual  is  not  narcotized.  The  patient's  nutrition  may  be 
improved  by  the  use  of  large  doses  of  milk,  and  the  milk 
should  be  prepared  so  that  it  is  not  obnoxious  to  the  patient. 
It  may  be  flavored  with  salt  or  any  kind  of  flavor,  or  it  may 


70  SPECIFIC    INFECTIONS. 

be  given  in  the  form  of  junket.  There  is,  of  course,  no  neces- 
sity for  the  use  of  a  simple  liquid  diet,  but  if  the  patient  can, 
and  will  eat,  foods  such  as  toast,  junket,  potatoes,  cereals  and 
finely  chopped  beef  may  be  given. 

As  a  prophylactic  measure  in  this  form  of  miliary  tuber- 
culosis, indeed,  of  all  other  forms  of  tuberculosis,  careful 
search  must  be  made  of  the  body  for  tubercular  foci.  Acces- 
sible tuberculous  glands  should  be  removed,  and  if  there  is  a 
tuberculous  joint,  this  should  be  treated  in  the  proper  way. 
Tuberculosis  of  the  genito-urinary  organs  should  be  cured,  if 
it  is  at  all  possible ;  indeed,  every  precaution  taken  to  rid  the 
body  of  any  focus  of  tuberculosis,  for  a  seemingly  harmless 
tuberculous  area  may  very  easily  light  up,  and  the  individual 
become  the  subject  of  a  general  fatal  tuberculosis  without 
warning. 

Pulmonary  Form  of  Miliary  Tuberculosis.  In  this  form  of 
tuberculosis  the  symptoms  are  largely  pulmonary  from  the 
start — there  is  cough,  and  very  rapid  breathing,  with  the 
physical  signs  of  a  general  bronchitis.  Percussion  sounds  are 
negative  as  to  signs  of  consolidation.  From  the  very  begin- 
ning there  is  a  high  degree  of  cyanosis,  entirely  out  of  propor- 
tion to  the  physical  signs  in  the  chest.  The  temperature  is 
irregular,  and  the  pulse  is  very  feeble.  Occasionally,  but 
rarely,  the  sputum  contains  tubercle  bacilli. 

The  same  measures  may  be  employed  here  for  the  relief 
of  fever  and  pain  as  in  the  typhoid  form.  The  use  of  opium 
for  the  control  of  the  cough  is  much  more  justifiable  than  it 
is  in  cases  of  any  curable  pneumonic  condition.  The  case, 
when  the  diagnosis  is  properly  made,  is  necessarily  fatal,  and 
all  symptomatic  relief  should  be  given  to  the  patient,  even  to 
the  point  of  mild  narcosis  by  proper  drugs. 

Fresh  air  is  often  of  the  greatest  moment  in  giving  relief 
to  the  breathing.  Occasionally,  oxygen  is  of  great  value  to 
relieve,  temporarily  at  least,  the  cyanosis. 

Tuberculous  meningitis  is  a  form  of  miliary  tuberculosis 
which  is  extremely  common,  particularly  in  children.  The 
disease  may  begin  with  a  convulsion.  One  convulsion  may 
succeed  another,  till  the  death  of  the  child  supervenes  in  a 
very  short  time,  but  this  is  not  the  rule.  Usually  there  is  a 
malaise,  an  irregular  fever,  the  same  irregular  pulse  as  occurs 


TUBERCULOSIS.  71 

in  typhoid  forms  of  miliary  tuberculosis,  then  rapidly  beg'in- 
ning-  meningeal  symptoms,  persistent  headache ;  a  very  marked 
tache,  which  is  extremely  common ;  signs  of  meningeal  irrita- 
tion as  evidenced  by  paralyses;  paralysis,  sometimes  fleeting, 
of  the  ocular  muscles ;  stiffness  of  the  neck,  Kernig  sign, 
Babinski  sign,  and  then  convulsion,  stupor  and  coma  end  the 
scene.  When  these  conditions  first  appear  the  spinal  canal 
should  be  at  once  tapped,  in  order  to  make  a  diagnosis  as  to  the 
condition  of  the  meninges.  As  the  case  proceeds,  the  sight  is 
soon  lost,  the  child  develops  conjunctivitis,,  the  neck  becomes 
markedly  stifif,  and  paralyses  of  other  muscles  may  occur. 
The  child  gradually  sinks  into  coma,  Cheyne-Stokes  breathing 
may  occur,  and  usually  does  supervene  long  before  the  end 
happens. 

As  far  as  the  w^riter  knows,  tuberculous  meningitis  is  always 
fatal,  but  much  relief  can  be  given  toward  the  cessation  of  the 
convulsions  and  the  occurrence  of  head  pains,  by  systematic 
tapping  of  the  spinal  canal.  Here  the  relief  of  pressure  will 
often  stop  the  convulsions,  and  sometimes  the  headache, 
which  has  been  extremely  severe,  will  be  made  to  disappear 
entirely  by  daily  tappings  of  the  spinal  canal.  In  young  chil- 
dren, where  the  fontanels  are  open,  a  very  marked  depression 
of  the  fontanel  can  be  seen  after  tapping,  and  coincident  with 
this  depression  convulsive  seizures,  whether  they  be  general 
convulsions  or  not,  often  disappear. 

Tuberculous  Adenitis.  It  has  been  proved  that  practically 
all  children  over  .3  years  of  age  have  tuberculosis,  usually  in 
the  lymphatic  glands.  Of  course,  many  of  these  cases  of  tuber- 
culosis are  not  at  all  possible  of  diagnosis  during  life,  but 
tuberculosis  of  the  lymph-glands,  giving  rise  to  an  inflamma- 
tion of  these  nodes,  is  often  the  very  earliest  stage  of  tuber- 
culosis in  any  form.  The  lymph-nodes  in  the  neck  are  perhaps 
the  most  commonly  affected.  Generalized  tuberculous  adenitis 
is  quite  common.  Sometimes  this  occurs  as  an  acute  disease, 
the  glands  being  enlarged  over  all  but  the  palpable  surfaces 
of  the  body  within  a  very  short  time.  The  disease  in  this  form 
may  run  a  very  short  course,  so  far  as  fever  is  concerned,  and 
the  glands  gradually  disappear,  or  become  much  smaller. 

The  enlargement  of  the  mesentery  g"lands,  tabes  mesen- 
terica,  is  quite  a  common  affection,  and  is  particularly  fre- 


72  SPECIFIC    INFECTIONS. 

quent  in  young  children.  The  enlargement  of  these  glands 
gives  rise  to  a  very  marked  abdominal  mass,  ascites  sometimes 
occur,  and  the  subject  rapidly  emaciates. 

Tuberculosis  of  the  bronchial  glands,  or  the  tracheobron- 
chial glands,  is  quite  common,  and  sometimes  gives  rise  to 
marked  symptoms.  Occasionally,  pressure  on  the  trachea,  or 
on  the  bronchus,  gives  rise  to  stridor,  and  harsh  cough,  which 
is  very  constantly  mistaken  for  whooping-cough.  The  writer 
has  notes  of  one  case  where  the  glands  of  the  posterior  media- 
stinum were  large  enough  to  make  pressure  on  the  esophagus, 
and  cause  an  absolute  obstruction  of  the  gullet. 

Cervical  adenitis  is  the  one  form  of  tubercular  inflamma- 
tion of  the  glands  which  offers  a  chance  of  cure  by  surgical 
interference.  When  these  glands  are  enlarged  frequently  they 
become  inflamed,  caseous  in  the  center,  and  often  give  rise  to 
large  abscesses  in  the  neck,  which,  if  undisturbed,  rupture 
through  the  skin,  continue  to  suppurate  for  a  long  while,  and 
finally  produce  unsightly  scars.  When  the  cervical  lymph- 
nodes  are  enlarged  and  evidently  tuberculous,  the  best  treat- 
ment is  unquestionably  removal  of  these  glands  before  they 
suppurate,  so  that  the  entire  chain  of  glands  may  be  removed 
without  a  very  great  likelihood  of  their  returning. 

If  great  objection  is  made  to  the  removal  of  the  glands, 
the  suppurating  glands  may  simply  be  incised  and  carefully 
drained,  although  this  is  not  a  good  surgical  procedure.  All 
the  time  these  glands  are  enlarged,  and  during  the  process  of 
suppuration,  the  patient  should  be  under  the  best  hygienic 
conditions,  living  out-of-doors,  given  an  abundance  of  food, 
and  a  general  tonic  medication.  The  best  medication  to  give 
under  these  occasions  are  the  syrup  of  iodid  of  iron,  together 
with  strychnin  in  proper  doses,  but  I  repeat  that  the  glands 
had  best  be  removed  early  in  the  course  of  enlargement. 

The  treatment  of  tabes  mesenterica,  of  necessity,  is  one 
of  hygiene  and  feeding.  The  effect  of  fresh  air  and  an  abund- 
ance of  food  upon  tuberculous  children,  who  are  virtually  at 
death's  door,  is  scarcely  believable.  Finally  they  may  be  re- 
lieved of  many  of  their  acute  symptoms  by  simple  hygienic 
and  medicinal  treatment  much  like  that  used  in  cervical 
adenitis. 


TUBERCULOSIS.  ^Z 

The  same  remarks  may  be  applied  to  tracheobronchial 
glands  which  give  symptoms.  Here,  on  one  or  two  occasions, 
the  use  of  .r-ray  seems  to  have  caused  a  retrogression  of  the 
size  of  the  glands,  which  has  brought  about  actual  sympto- 
matic cure. 

The  use  of  tuberculin  in  enlarged  lymphatic  glands  is,  per- 
haps, occasionally  followed  by  good  results.  The  administra- 
tion of  tuberculin  here,  in  the  writer's  experience,  is  best  done 
by  beginning  with  a  very  small  dose,  about  %ooo  of  a  milli- 
gram, and  very  gradually  increasing  the  dose,  being  careful 
to  avoid  any  reactions.  A  course  of  tuberculin  may  be  con- 
tinued for  two  or  three  months,  and  then  an  intermission 
taken,  and  after  four  or  five  months  more  a  second  course  may 
be  given,  often  with  good  results. 

This  use  of  tuberculin  applies  to  the  treatment  of  tuber- 
culosis of  any  part  of  the  body.  It  should,  however,  never 
be  used  to  the  exclusion  of  hygienic  methods  and  good  feed- 
ing. 

Tuberculous  Pleurisy.  It  is  claimed  by  some  writers  that  all 
attacks  of  pleurisy  are  tuberculous  in  origin.  To  the  writer's 
mind  this  is  probably  an  exaggeration,  but  the  number  of 
cases  of  fibrinous  and  serofibrinous  pleurisy,  which  are  tuber- 
culous, is  unquestionably  very  large. 

The  symptoms  are  those  of  a  pleurisy  arising  under  any 
other  conditions— fever,  pain  in  the  side,  physical  signs  of  a 
friction  sound  in  the  beginning-,  and  afterwards  signs  of  a 
liquid  in  the  chest.  Frequently  the  onset  of  this  pleurisy  is 
extremely  insidious,  the  patient  having  little  or  no  pain,  and 
presenting  himself  to  the  physician  simply  with  dyspnea. 
Examination  will  reveal  the  collection  of  a  large  amount  of 
pleural  effusion,  or  it  may  be  that  there  has  been  no  effusion, 
inasmuch  as  the  pleurisy  has  been  largelv  fibrinous  in 
type,  and  the  movements  of  the  affected  side  of  the  chest 
are  ver}-  greatly  limited  by  the  formation  of  this  new  fibrinous 
material. 

The  treatment  of  tuberculous  pleurisy,  in  the  acute  cases, 
consists  of  rest  in  bed,  strapping  of  the  side,  and  the  adminis- 
tration of  opiates,  if  the  pain  is  verv  severe.  If  an  exudate 
occurs,  as  it  very  frequently  does,  perhaps  the  best  treatment 
is  tapping,  precautions  being  taken  that  this  slight  operation  be 


74  SPECIFIC    INFECTIONS. 

done  under  strict  aseptic  precautions,  and  that  the  site  of  the 
aspiration  first  be  sterilized,  then  made  anesthetic  by  the  use 
of  a  weak  solution  of  cocain  or  novocain,  ^  per  cent,  solu- 
tion being  the  proper  strength,  the  skin  first  being  infiltrated, 
and  then  the  underlying  tissues.  Through  this  anesthetized 
area  a  slight  incision  should  be  made  with  a  scalpel,  and 
through  this  incision  the  trocar  and  cannula  can  be  plunged, 
practically  without  pain  to  the  patient.  With  these  necessary 
precautions  a  chest  may  be  tapped  without  the  sliglitest  bit 
of  danger  to  the  patient. 

In  some  cases  of  undoubted  tuberculous  pleurisy  with 
efifusion,  the  effusion  recurs  very  frequently  after  each  tap- 
ping. The  question  then  arises  how  often  such  a  pleural  effu- 
sion shall  be  tapped.  The  rule  which  it  seems  to  me  proper 
to  follow  is  to  tap  three  times  in  succession,  each  tapping 
being  performed  when  a  mechanical  interference  of  respiration 
and  circulation  appear.  If  the  liquid  reappears  after  the  third 
tapping,  then  tapping  should  never  be  done,  except  when 
mechanical  interference  makes  it  imperative.  These  patients 
with  a  chronic  recurring  pleural  effusion  must  be  put  upon 
all  the  treatment  that  is  necessary  for  a  general  tuberculosis — 
rest  when  they  have  fever,  with  an  abundance  of  food  and 
abundance  of  fresh  air.  As  a  rule,  if  this  method  of  tapping 
is  carried  out,  the  effusion  will  reach  a  certain  size,  and  give 
no  signs  of  mechanical  interference  for  many  weeks,  and 
sometimes  for  months.  Finally,  they  cease  giving  rise  to  any 
mechanical  effect,  because  doubtless  there  is  a  formation  of 
fibrous  tissue  to  the  exclusion  of  liquid. 

Tuberculous  Peritonitis.  Tuberculous  peritonitis  may  occur 
as  a  miliary  process  in  the  course  of  a  general  miliary  tuber- 
culosis, and  under  these  conditions  it  is  usually  quickly  fatal. 
However,  the  tuberculous  process  may  affect  particularly  the 
omentum  and  the  parietal  peritoneum,  and  often  gives  rise  to 
large  masses,  which  can  be  easily  palpated,  and  frequently 
these  masses  are  accompanied  by  an  effusion.  This  effusion 
is  very  likely  to  be  not  free  in  the  peritoneal  cavity,  but  con- 
nected between  bands  of  fibrinous  tissue  which  are  formed  on 
account  of  this  process.  Sometimes  there  is  very  little  effu- 
sion, and  the  intestines  are  bound  into  one  mass  of  thick 
fibrous  exudate. 


TUBERCULOSIS.  75 

The  symptoms  are  abdominal  pain,  tenderness  on  palpa- 
tion, the  formation  of  masses  in  the  abdominal  cavity,  and 
often  the  presence  of  liquid.  It  is  a  remarkable  fact  that  cer- 
tain cases  of  tubercular  peritonitis  seem  to  recover  absolutely 
by  simple  opening-  of  the  abdominal  wall.  But  it  has  been 
observed  that  frequently  these  apparent  cures  due  to  opening 
the  abdominal  wall  are  only  temporary,  and  this  procedure 
certainly  should  not  take  the  place  of  general  hygienic  treat- 
ment. 

A  patient  with  beginning  tuberculous  peritonitis  should  be 
put  to  rest  under  all  the  proper  hygienic  surroundings  sug- 
gested for  tuberculosis  of  any  other  organs. 

Duringf  this  treatment  careful  search  must  be  made  for 
tuberculous  foci,  such  as  tuberculosis  of  the  appendix,  of  the 
fallopian  tubes,  and,  indeed,  for  these  foci  in  any  portion  of 
the  body.  If  they  are  accessible,  they  should  be  removed,  and 
the  general  hygienic  treatment  continued.  If,  in  spite  of  gen- 
eral treatment,  an  effusion  into  the  peritoneal  cavity  occurs 
and  continues,  a  laparotomy  is  certainly  indicated,  and,  as 
already  stated,  drainage  by  a  simple  laparotomy  often  will 
cause  a  cessation  of  the  active  progress  of  the  disease.  It 
seems  to  me,  in  spite  of  the  statistics  which  show  that  tuber- 
culosis of  the  peritoneum  after  the  abdomen  has  been  opened, 
tend  to  relapse,  or  tend  to  become  chronically  ill,  the  indica- 
tion for  laparotomy  is  rather  to  do  it  early  than  late.  Cer- 
tainly any  procedure  which  is  followed  by  a  cessation  of  the 
local  inflammation,  as  laparotomy  in  tuberculous  peritonitis 
very  frequently  does,  is  worthy  of  an  early  trial,  and  should 
not  be  used  as  a  last  resort. 

Gcnito-urinary  Tuberculosis.  Tuberculosis  of  the  Bladder 
gives  simply  the  symptoms  of  cystitis.  It  can  be  positively 
diagnosed  by  a  cystoscopic  examination  of  the  bladder,  and  the 
discovery  of  tuberculous  lesions  in  the  bladder  wall. 

The  treatment,  first  of  all,  must  be  a  general  treatment  of 
the  tuberculous  condition,  and  then  local  conditions  best 
applied  by  an  individual  skilled  in  cystoscopy.  As  this  condi- 
tion, is  practically  always  secondary,  and  usually  secondary 
to  tuberculosis  of  the  kidney,  at  the  time  that  the  diagnosis 
of  tuberculosis  of  the  bladder  is  made,  the  ureter  should  be 
carefully  examined.     Usually  at  the  ureteral  orifice  there  is 


76  SPECIFIC    INFECTIONS. 

irritation,  and  sometimes  actual  inflammation  showing  that 
the  disease  is  primary  in  the  kidney. 

Tuberculosis  of  the  Kidney.  This  disease,  not  rarely  pri- 
mary, gives  rise  to  symptoms  of  cystitis,  with  much  pus  in 
the  urine.  Sometimes  there  is  local  tenderness  over  the  kid- 
ney, and  an  enlarged  kidney  can  be  discovered,  but  long 
before  the  time  of  the  renal  enlargement  and  a  conversion  of 
the  kidney  into  masses  of  tubercular  foci,  the  diagnosis  should 
be  made.  This  diagnosis  should  be  made  by  a  routine  exami- 
nation of  the  bladder  by  one  skilled  in  the  use  of  the  cysto- 
scope  in  every  case  of  cystitis,  or  with  the  symptoms  of 
cystitis.  If  the  bladder  is  found  to  be  free,  if  a  ureteral  open- 
ing is  found  to  be  irritated,  and  this  has  the  appearance  of  a 
tuberculous  lesion,  then  the  ureter  on  the  alTected  side 
should  be  carefully  catheterized,  and  the  urine  from  that  side 
be  examined  for  tubercle  bacilli.  If,  after  catheterization  of 
the  ureter  on  the  opposite  side  the  other  kidney  is  found  to 
be  functioning  and  entirely  free  of  tuberculosis,  then  cer- 
tainly surgical  removal  of  the  affected  kidney  is  the  proper 
procedure.  This  should  be  done,  however,  only  after  con- 
sultation with  a  cystoscopist  skilled  in  the  examination  of  the 
kidneys  by  the  ureteral  catheter. 

Electrotherapy  and  x-rsij  have  been  suggested  in  the 
treatment  of  tuberculous  diseases  of  the  genito-urinary  or- 
gans, just  as  it  has  been  suggested  for  the  treatment  of  many 
diseases  in  most  other  parts  of  the  body,  but  if  the  disease  is 
limited  to  one  kidney,  surely  that  kidney  should  be  removed, 
rather  than  to  attempt  the  removal  of  the  disease  by  an  uncer- 
tain process  like  the  use  of  electricity. 

SYPHILIS. 

Syphilis  is  transmitted  from  one  individual  to  another  by 
means  of  material  containing  the  specific  organism,  the  Tre- 
ponema pallidum.  This  micro-organism,  as  is  well  known,  is 
a  spirochete,  and  is  the  sole  cause  of  syphilis,  a  disease  which 
is  either  acquired  or  congenital.  When  acquired,  it  is  trans- 
mitted usually  through  sexual  intercourse,  although  the  dis- 
ease is  not  always  venereal,  and  may  be  transmitted  by  other 
means,  by  kissing,  by  transference  of  the  virus  through  drink- 


SYPHILIS.  77 

ing  cups,  towels,  penholders,  indeed  by  the  medium  of  any 
article  which  has  been  infected  by  a  syphilitic,  and  then  used 
by  a  non-syphilitic. 

Congenital  syphilis  is  transmitted  from  the  mother  to  the 
child.  The  mother  may  be  the  innocent  means  of  transmis- 
sion of  syphilis,  the  father  having  the  active  disease,  but  the 
mother  is  always  infected,  as  shown  by  the  presence  of  a 
Wassermann  reaction  in  her  blood,  though  she  may  give 
no  symptoms  or  signs  of  active  syphilis.  The  congenitally 
syphilitic  child  transmits  the  disease  to  a  nurse  when  she  is 
allowed  to  suckle  it;  indeed,  the  syphilitic  child  may  transmit 
the  disease  to  healthy  individuals  when  the  active  lesions  are 
handled  by  the  nurse,  or  the  exudation  from  these  lesions  are 
in  any  way  permitted  to  contaminate  the  mucous  membranes 
or  abraded  skin  of  non-immune  individuals.  For  purposes  of 
convenience,  and  for  description,  syphilis  is  divided  into  the 
primary  stage,  the  secondary  stage,  and  the  tertiary  stage. 

All  three  stages  of  syphilis  are  transmissible,  the  primary 
and  the  secondary  stages  much  more  readily  than  the  tertiary 
stage,  although  the  last  named  is  certainly  transmissible,  as 
shown  by  inoculation  experiments.  From  practical  experi- 
ence, however,  it  is  proven  that  in  this  tertiary  stage  the  dis- 
ease is  rarely  transmitted  from  one  human  being  to  another. 

The  primary  stage  is  represented  in  the  time  from  the 
appearance  of  the  chancre  to  the  beginning  of  the  secondary 
symptoms.  This  primary  stage  lasts  approximately  from  six 
weeks  to  three  months. 

The  secondary  stage  begins  with  the  appearance  of  fever, 
(which  may  last  during  the  entire  stage  if  the  case  is  un- 
treated), sometimes  closely  resembling  typhoid  fever.  Other 
manifestations  at  this  phase  of  the  disease  are  eruptions  on  the 
skin  and  mucous  membranes,  with  anemia,  general  adenitis, 
sore  throat  and  arthritis. 

There  is  no  sharply  drawn  line  between  the  secondary  and 
tertiary  stage,  but  the  tertiary  stage  is  characterized  bv  spe- 
cial lesions  of  tlie  skin,  bones,  nervous  system  and  viscera. 

There  is  no  tissue  of  the  body  which  at  one  stage  or  the 
other  cannot  be  affected  by  the  lesions  of  syphilis. 


78  SPECIFIC    INFECTIONS. 

TREATMENT. 

As  prophylactic  safeguards,  public  and  personal  hygiene 
are  of  the  first  importance  in  dealing  with  syphilis.  The  laws 
which  make  it  legal  to  establish  houses  of  prostitution,  so 
far  as  the  author  knows,  have  failed  to  control  the  disease, 
syphilis  being  about  as  frequent  in  controlled  districts,  or 
countries  where  there  are  controlled  districts,  as  it  is  in  other 
uncontrolled  countries.  The  most  helpful  means  of  controll- 
ing the  disease  is  probably  by  a  campaign  of  education.  How- 
ever, this  campaign  of  education  must  certainly  be  conducted 
in  a  manner  which  lacks  all  the  elements  of  hysteria.  It 
would  seem  to  me  that  education  which  begins  in  the  school 
would  tend  rather  to  the  initiation  of  venereal  habits  than 
otherwise.  It  is  certainly  correct,  however,  that  individuals 
at  the  time  of  puberty,  or  near  the  time  of  puberty,  should 
know  that  there  is  such  a  disease  as  syphilis,  and  that  it  is 
transmitted  by  sexual  intercourse,  that  it  may  be  transmitted 
in  other  ways,  and  they  should  be  taught  the  actual  physical 
dangers  of  illegitimate  intercourse,  as  well  as  the  moral 
deterioration  which  comes  through  such  practice.  They 
should  know  that  the  danger  involves  not  only  themselves, 
but  those  with  whom  they  are  in  intimate  contact,  and  their 
unborn  children. 

As  I  have  said,  the  manner  in  which  this  knowledge  shall 
be  taught  to  adolescents  is  a  subject  which  need  not  be  taken 
up  here,  but  it  is  doubtful  if  it  can  be  safely  and  properly  done 
through  public  lectures  to  the  young,  which  are  now  so  pop- 
ular. We,  as  physicians,  owe  it  to  our  patients,  however, 
when  we  are  asked  how  they  can  prevent  syphilis,  to  give 
them  instructions  which  will  protect  them,  at  least,  to  a  cer- 
tain degree.  Of  course,  the  rule  which  is  certain  to  prevent 
the  spread  of  the  disease,  in  the  large  majority  of  cases,  is  to 
abstain  from  illegitimate  intercourse,  or  intercourse  with 
anyone  wlio  is  known  to  be  afifected,  or  may  be  suspected  of 
being  infected  with  syphilis.  This,  of  course,  would  rule  out 
the  great  majority  of  cases  of  syphilis.  However,  such  advice 
is  rarely  heeded,  and  one  is  therefore  forced  to  give  other 
rules.  The  first  is  that  the  general  health  of  the  individual 
should  be  kept   up  to  the  highest  tone.     Second,  that  inter- 


SYPHILIS.  79 

course  must  not  be  held  with  those  who  are  suspected  of 
being  syphilitic.  Third,  if  they  do  not  choose  to  follow  this 
last  rule,  then  they  may  be  told  that  cleanliness  of  the  genital 
organs,  immediately  before  and  immediately  after  sexual  in- 
tercourse, will  prevent  a  certain  number  of  cases  of  infection. 
If  the  genitals  are  covered  with  a  30  per  cent,  calomel  oint- 
ment this  will  prevent  a  certain  number  of  cases.  Immediate 
attention  to  any  suspicious  sore  on  the  genitals  after  inter- 
course will  also  prevent  a  number  of  cases  of  infection  devel- 
oping into  an  actual  luetic  infection. 

Of  all  these  means  of  prevention,  unquestionably  the  first, 
to  forego  illicit  intercourse,  is  the  proper  one,  and  the  one 
that  we,  as  physicians,  should  insist  upon.  Perhaps  phy- 
sicians are  not  thought  to  be  necessarily  mentors  to  our 
patients'  morals,  but  it  strikes  me  that  if  there  is  one  duty 
which  is  incumbent  on  the  physician  it  is  to  see  that  at  least 
by  advice  and  by  example  his  patients  shall  be  taught  that  a 
clean  and  moral  life  will  lead  to  health.  As  I  said  before, 
this  advice  is  very  generally  disregarded,  but  it  certainly 
should  be  given,  and  given  earnestly,  and  then  his  duty  in 
this  respect  will  have  been  accomplished  by  the  physician. 

Since  the  discovery  of  the  infecting  micro-organism,  it  is 
known  that  by  certain  measures  it  may  be  seen  in  the  primary 
sore.  Every  primary  sore  should  have  the  exudate  from  it 
carefully  examined  by  an  expert  in  the  use  of  the  dark  field 
microscope,  so  that  a  very  early  diagnosis  may  be  made.  To 
wait  for  the  typical  characteristic  secondary  symptoms  is  to 
wait  until  the  disease  has  become  generalized,  and  then  treat- 
ment is  much  less  efficacious,  and  necessarily  more  prolonged. 
Excision  of  the  primary  sore  when  it  is  diagnosed  as  a  chancre 
should  be  done  at  once ;  the  earlier  the  better  the  chance  of 
limiting  the  infection.  Where  practicable,  an  immediate  dose 
of  neosalvarsan  or  of  salvarsan  should  be  given,  to  be  fol- 
lowed immediately  by  the  efficient  administration  of  some 
form  of  mercury.  A  word  of  caution  in  regard  to  the  use  of 
salvarsan  and  neosalvarsan.  The  intravenous  method  is  un- 
questionably the  most  efficient  means  of  administering  this 
most  useful  drug.  However,  intravenous  medication  at  the 
best  is  not  entirely  free  from  danger,  and  in  my  opinion  intra- 
venous injections   should  be   given   only  by   those   skilled   in 


80  SPECIFIC    INFECTIONS. 

such  procedures,  and  no  one  who  has  not  had  proper  instruc- 
tions in  intravenous  injections  of  salvarsan  should  attempt  it. 
There  is  much  danger  of  phlebitis,  infiltration  of  the  tissue, 
and  sloughing  of  the  parts  under  certain  conditions.  When 
the  administration  is  properly  done,  these  accidents  do  not 
occur.  The  following  is  the  method  used  by  Prof.  A.  C.  Wood. 
The  safe  administration  of  salvarsan  demands  the  strictest 
attention  to  certain  fundamental  principles  : 

1.  Scrupulous  asepsis  must  be  maintained  in  every  step  of 
the  preparation  of  the  solution,  and  in  the  administration  of 
the  drug. 

2.  Careful  attention  to  the  printed  instructions  contained  in 
each  package. 

3.  The  water  used  in  making  the  solution,  and  the  salt 
solution,  should  be  freshly  distilled  if  possible.  If  not  freshly 
distilled,  it  must  be, -at  least,  thoroughly  boiled  and  free  from 
any  particles  or  sediment. 

4.  The  operator  must  be  certain  that  the  needle  is  in  the 
vein,  before  permitting  the  solution  of  salvarsan  to  flow.  If 
any  of  the  drug  escapes  into  the  tissues  about  the  vein,  a  very 
painful,  dense  induration  results,  or  there  may  be  extensive 
sloughing  of  the  tissues.  The  induration  resulting  from  the 
salvarsan  persists  for  months. 

The  method  of  administration  advised  by  Ehrlich  was  to 
use  50  mils  (1.7  f^)  of  the  sterile,  freshly  boiled  water  for  each 
0.1  Gm.  (2  gr.)  of  salvarsan  prepared.  There  is  a  growing 
tendency  to  dissolve  the  drug  in  a  much  smaller  amount  of 
water.  Some  authorities  administer  the  maximum  dose,  i.e., 
0.6  Gm.  (10  gr.)  in  30  mils  (1  f^)  of  water;  which  is  introduced 
by  the  glass  syringe  of  the  Luer  type.  The  latter  method 
simplifies  the  amount  of  apparatus  and  the  administration  very 
greatly,  but  it  may  still  be  open  to  question  whether  it  should 
be  allowed  to  generally  supersede  the  technic  employed  by 
Ehrlich. 

For  those  with  limited  experience  the  original  method  is 
certainly  to  be  preferred.  It  is  desiral^le  to  provide  two  grad- 
uated glass  reservoirs,  of  300  mils  (10  fj)  capacity,  each  being 
connected,  with  some  3  feet  of  rubber  tubing  to  a  3-way  cock, 
to  which  is  attached  the  hollow  needle.  The  salvarsan  solution 
is  introduced  into  one  vessel,  and  normal  salt  solution  in  the 


SYPHILIS.  81 

other.  All  air  bubbles  must  be  carefully  eliminated.  After  the 
needle  is  introduced  into  the  vein,  the  salt  solution  is  allowed 
to  flow;  and  if  several  mils  of  the  fluid  have  passed  without 
causing  a  visible  inhltration  under  the  skin,  it  may  be  assumed 
that  the  fluid  has  passed  into  the  vein.  The  cock  may  then  be 
turned  to  permit  the  salvarsan  to  flow.  If  during-  the  admin- 
istration the  patient  complains  of  pain  at  the  site  of  the  punc- 
ture, or  if  there  is  any  sign  of  infiltration,  or  other  reasons  to 
suspect  that  the  needle  may  have  been  displaced,  the  cock 
should  be  at  once  turned  to  permit  the  salt  solution  to  flow. 
In  this  way  one  may  determine  whether  or  not  the  point  of  the 
needle  is  still  in  the  vein.  If  it  is  not,  it  should  be  withdrawn 
and  a  fresh  puncture  made  at  some  other  suitable  point. 

Neosalvarsan  is  to  be  administered  in  exactly  the  same  way 
as  salvarsan,  except  that  the  solution  of  the  former  does  not 
require  neutralizing  with  sodium  hydroxid.  On  account  of 
its  free  solubility  and  its  milder  irritating  qualities,  it  is  more 
suitable  for  administration  in  concentrate  solution.  The  maxi- 
mum adult  dose  of  0.9  Gm.  (14  gr.)  has  been  administered  in 
as  little  as  10  niils  (2.7  fo)  of  water.  The  writer  is  not  inclined, 
however,  to  recommend  this  method  for  general  administra- 
tion at  the  present  time.  Ehrlich  recommended  the  use  of  25 
mils  (6^  fo)  of  water,  or  salt  solution,  for  each  0.15  Gm. 
(2^  gr.)  of  neosalvarsan. 

Mercury  may  be  given  by  the  mouth,  by  inunctions,  and 
by  intramuscular  injections.  By  the  mouth  perhaps  the  best 
preparation  is  the  protiodid  of  mercury.  This  may  be  given 
in  jk;-grain  (0.016  Gm.)  doses  three  times  a  day,  gradually 
increasing  the  number  of  doses  until  soreness  of  the  gums  is 
noticed.  During  the  administration  of  mercury  in  this  or 
any  other  form,  the  mouth  is  to  be  kept  scrupulously  clean 
by  brushing  several  times  during  the  day,  and  by  using  a 
simple  alkaline  mouth-wash,  either  Dobell's  solution,  boric 
acid  solution,  or  one  of  the  pleasant  proprietary  solutions. 
The  liquor  antisepticus,  of  the  United  States  Pharmacopeia, 
is  quite  efficient  and  pleasant  as  a  mouth-wash,  and  should 
be  used  in  preference  to  proprietary  preparations  of  the  same 
character. 

After  two  weeks  the  initial  dose  of  neosalvarsan  or  salvar- 
san should  be  repeated,  again  to  be  followed  by  a  course  of 

6 


82  SPECIFIC    INFECTIONS. 

mercury,  and  this  should  be  kept  up  until  four  or  five  injec- 
tions of  neosalvarsan  or  salvarsan  have  been  given,  the  inter- 
vals between  the  doses  being  used  for  the  purpose  of  admin- 
istering mercury.  Besides  the  administration  of  mercury  in 
the  form  of  protiodid,  mercurial  inunctions  may  be  used ; 
a  drachm  (4  Gm.)  of  the  mercurial  ointment  should  be 
rubbed  into  the  portions  of  the  body  covered  by  thin  skin, 
i.e.,  the  axillse  and  the  inner  aspects  of  the  thighs.  These 
inunctions  should  be  given  every  day,  for  six  or  seven  days, 
and  then  omitted^  for  four  or  five  days.  The  rubbing  is  best 
done  by  an  attendant,  who  should  have  the  hands  protected 
by  rubber  gloves ;  it  should  take  at  least  a  half  an  hour  to  rub 
in  a  drachm  of  the  ointment,  until  it  has  entirely  disappeared 
from  the  surface. 

Another  method  of  administering  the  ointment  is  to  put 
it  upon  the  soles  of  the  feet,  and  then  encase  the  feet  in  a 
thick  woolen  stocking,  but  this  method  is  uncleanly,  and  is 
not  to  be  recommended  as  a  usual  procedure. 

The  intramuscular  injections  of  mercury  is  an  extremely 
convenient  and  efficient  way  of  administering  this  drug.  It 
may  be  given  in  the  form  of  salicylate  of  mercury,  10  grains 
(0.6  Gm.)  to  an  ounce  of  a  mineral  oil,  preferably  albolin. 
This  is  given  in  doses  of  10  mils  (160  w.),  deep  into  the  muscles. 
If  it  is  given  into  the  subcutaneous  tissue  it  is.  not  absorbed  so 
well,  and  it  is  quite  painful,  so  that  a  long  needle  should  be  used, 
which  will  convey  the  material  into  the  muscle  itself.  In  the 
place  of  salicylate  of  mercury,  gray  oil,  a  suspension  of  mer- 
cury in  oil,  may  be  used.  An  extremely  carefully  prepared 
mercurial  ointment  is  first  made,  and  then  a  certain  portion 
of  this  is  rubbed  up  with  pure  olive  oil.  The  great  objection 
to  gray  oil  is  the  difiiculty  of  its  proper  preparation,  and  the 
inadvisability  of  using  a  preparation  which  is  not  accurately 
made.  These  intramuscular  injections  are  given  at  intervals 
of  two  or  three  days,  care  being  taken  that  not  enough  mercury 
is  given  to  cause  severe  salivation,  and  the  same  rule  should  be 
followed  as  is  observed  in  using  mercury  internally.  When 
the  gums  begin  to  get  sore,  the  administration  should  be 
stopped.  In  severe  cases,  particularly  in  cerebral  cases,  I  have 
used  the  injection  every  day,  with  very  good  efifect.  Of  course, 
the  time  in  which  the  salivation  occurred  was  much  shorter, 


SYPHILIS.  83 

and  had,  therefore,  to  be  watched  more  carefully.  There  is 
some  danger  in  this  intramuscular  injections  of  mercurial  prep- 
aration, but  it  is  very  slight. 

First,  abscesses,  which  can  be  avoided  by  strict  asepsis. 

Second,  so-called  fat  embolism.  If  the  emulsion  chances 
to  be  injected  directly  into  a  vein,  the  oil  will  be  carried 
directly  to  the  lung,  causing  an  embolism  there.  This  acci- 
dent is  characterized  by  pain  in  the  side,  bloody  expectora- 
tion and  cough.  By  using  not  too  large  a  dose,  however,  the 
danger  is  extremely  slight. 

After  the  use  of  this  method  of  treatment  for  four  to  five 
months,  all  treatment  should  be  stopped  if  there  are  no  symp- 
toms, and  the  patient  allowed  to  go  with  a  simple  tonic  of 
iron  and  nux  vomica  for  two  months,  when  a  Wassermann 
reaction  is  taken.  If  the  reaction  is  positive,  then  the  treat- 
ment should  be  renewed.  If  it  is  negative,  an  interval  of  three 
months  may  be  allowed  to  elapse,  when  a  second  course  of 
five  or  six  treatments  such  as  described  is  again  given.  These 
intermittent  treatments  must  be  kept  up  for  at  least  three 
years  before  the  patient  can  be  considered  cured,  and  no  person 
should  be  pronounced  cured  until  he  has  had  at  least  two  nega- 
tive Wassermann  reactions  after  the  last  course  of  treatment. 

lodid  of  potassium  should  be  used  only  in  the  latter  part 
of  the  treatment,  in  the  tertiary  stage,  10  grains  (0.6  Gm.) 
of  iodid  of  potassium  given  three  times  a  day  is  efficient. 

Treatment  of  Lesions  of  the  Tertiary  Stage.  Every  patient 
under  suspicion  of  syphilis  should  have  a  Wassermann  reac- 
tion made.  If  this  is  positive,  then  active  treatment  should 
at  once  be  begun.  If  the  Wassermann  reaction  is  negative, 
and  the  symptoms  and  signs  of  syphilis  are  positive,  then  the 
active  treatment  should  be  begun,  in  spite  of  the  fact  that 
the  blood  is  negative.  Indeed,  after  the  administration  of  a 
dose  of  neosalvarsan  or  salvarsan,  the  Wassermann  reaction, 
which  was  at  first  negative,  may  become  positive.  Where 
the  question  is  of  great  importance,  and  the  blood  Wasser- 
mann is  negative,  the  spinal  canal  should  be  tapped  and  a 
Wassermann  test  made  of  the  spinal  fluid.  This  will  fre- 
quently be  positive  when  a  blood  reaction  is  negative. 

The  tertiary  stage  of  syphilis  and  those  cases  where  no 
syphilitic  symptoms  are  present,  but  a  Wassermann  is  posi- 


84  SPECIFIC   INFECTIONS. 

tive,  should  be  at  first  treated  by  intensive  use  of  neosalvar- 
san  or  salvarsan,  and  this  to  be  followed  by  mercury,  very 
much  after  the  same  plan  as  is  used  in  the  cases  of  secondary 
and  primary  stages.  lodid  of  potassium,  where  there  are 
visceral  lesions,  is  of  the  highest  importance ;  10  to  20  grains 
(0.6  to  0.2  Gm.)  three  times  a  day  will  cause  the  disappearance 
of  old  ulcers  and  visceral  lesions  very  promptly. 

The  action  of  iodid  of  potassium  is  perhaps  not  very  well 
understood ;  certainly,  it  is  not  the  same  sort  of  action  as  that 
of  mercury ;  it  is  not  a  spirochetocide,  and,  therefore,  it  does 
not  act  in  the  same  manner,  but  it  is  most  useful,  and  should 
be  used  in  all  tertiary  lesions. 

For  the  treatment  of  cerebrospinal  syphilis,  H.  F.  Swift 
and  A.  W.  M.  Ellis  evolved  a  method  of  treatment  of  this  dis- 
ease by  autosalvarsanized  serum  into  the  spinal  canal.  This 
has  been  proved  by  many  observers  to  prevent  advance  of  the 
disease,  and  to  convert  individuals  who  apparently  were  fast 
becoming  invalided,  into  fairly  normal  condition. 

The  subjoined  method  of  giving  these  injections  into  the 
spinal  canal  are  taken  from  an  article  by  Swift  and  Ellis. 

Technic  of  Subarachnoid  Injections. — One  hour  after  the  in- 
travenous injection  of  salvarsan  40  mils  (1^3  fo)  of  blood  are 
withdrawn  directly  into  the  bottle-shaped  centrifuge  tubes,  and 
allowed  to  coagulate,  after  which  it  is  centrifugalized.  The 
following  day  12  mils  (0.194  m.)  of  serum  is  pipetted  off  and 
diluted  with  18  mils  (0.292  m.)  of  normal  saline.  This  40  per 
cent,  serum  is  then  heated  at  56°  C,  (132.8°  F.)  for  one-half 
hour.  After  lumbar  puncture  the  cerebrospinal  fluid  is  with- 
drawn until  the  pressure  is  reduced  to  30  mm.  cerebrospinal  fluid 
pressure.  The  barrel  of  a  20-mils  (5^  fo)  Luer  syringe  (which 
has  a  capacity  of  about  30  mils  [8  fo])  is  connected  to  the 
needle  by  means  of  a  rubber  tube  about  40  cm.  long.  The 
tubing  is  then  allowed  to  fill  with  cerebrospinal  fluid  so  that 
no  air  will  be  injected.  The  serum  is  then  poured  into  the 
syringe  and  allowed  to  flow  slowly  into  the  subarachnoid  space 
by  means  of  gravity. 

At  times  it  is  necessary  to  insert  the  plunger  of  the  syringe 
to  inject  the  last  5  mils  (0.82  m.)  of  fluid.  It  is  important  that 
the  larger  part  of  the  serum  should  be  injected  by  gravity  and 
ii  the  rubber  tubing  is  not  more  than  40  cm.  long  the  pressure 


SYPHILIS.  85 

cannot  be  higher  than  400  mm.  Usually  the  serum  flows  in 
easily  under  even  a  lower  pressure.  By  the  gravity  method 
the  danger  of  suddenly  increasing  the  intraspinous  pressure  to 
the  danger  point,  such  as  might  occur  with  rapid  injection  with 
a  syringe,  is  avoided.  Frequently  there  is  a  certain  amount  of 
pain  in  the  legs,  commencing  a  few  hours  after  the  injection. 
The  pain  is  more  often  noticed  in  tabetics  than  in  patients  with 
cerebrospinal  syphilis.  It  can  usually  be  controlled  by  means 
of  phenacetin  and  codein.     Occasionally  morphin  is  required. 

Congenital  syphilis  is  best  treated  by  salvarsan  in  proper 
doses  when  the  child  is  a  year  old  or  over.  Before  that  time 
inunctions  of  mercury  ofifer  the  best  chance  of  relief.  A 
syphilitic  child  should  be  nursed  only  by  its  mother.  There 
is  great  danger  of  transmitting  the  disease  to  a  wet  nurse. 

The  patient  will  constantly  ask  the  physician  when  he  can 
get  married  after  he  has  contracted  syphilis.  Here,  again,  the 
advice  of  the  physician  is  frequently  not  followed,  but  never- 
theless, it  should  be  given  in  good  faith  to  all  those  who  ask 
it.  A  patient  should  not  be  allowed  to  marry  for  at  least 
three  years  after  having  contracted  syphilis,  and  after  having 
been  under  carefully  conducted  treatment  during  those  three 
years,  and  not  then  unless  two  carefully  conducted  Wasser- 
mann's  are  negative.  If  the  person  is  married,  he  should  cer- 
tainly be  advised  to  abstain  from  sexual  intercourse  with  his 
wife  until  at  least  two  years  have  passed.  Of  course,  if  the 
wife  is  already  infected  when  the  patient  is  seen  by  the  phy- 
sician, this  advice  need  not  be  given.  Most  of  the  inefficient 
treatment  of  syphilis  is  due  to  the  fact  that  patients  con- 
stantly cease  treatment  after  the  symptoms  have  disappeared. 
Just  how  to  overcome  this  fault  remains  for  the  physician 
himself  in  every  particular  case  to  decide ;  but  in  those  who 
are  neglectful,  and  in  those  who  are  intractable,  the  dangers 
of  syphilis  should  be  fully  explained  to  the  patient,  and  then, 
of  course,  whether  or  not  he  shall  carrv  out  the  treatment 
remains  with  himself.  On  the  other  hand,  nervous  individ- 
uals, particularly  if  they  be  married,  and  if  thev  be  intelligent, 
should  be  assured  that  syphilis  is  a  curable  disease,  and  if  the 
treatment  is  carried  out  properly,  and  hygiene  persisted  in. 
he  will  prevent  any  serious  after-effects,  and  can  prevent 
transmitting  it  either  to  his  wife  or  to  his  children. 


S6  SPECIFIC   INFECTIONS. 


GONOCOCCUS    INFECTIONS. 

There  is,  perhaps,  no  disease  so  little  understood  by  the 
laity  as  is  gonorrhea.  This  misunderstanding  unfortunately 
sometimes  extends  to  the  ranks  of  the  medical  profession.  Be- 
ginning as  it  usually  does  as  infection  of  the  urethra  in  the 
male,  and  of  the  urethra  and  the  vagina  in  the  female,  it  is 
considered  a  purely  local  infection.  The  infection  is  certainly 
local  in  the  beginning  of  the  case,  but  very  frequently — more 
frequently  than  is  usually  suspected — general  infections,  a  true 
septicemia,  and  local  infections  such  as  arthritis,  diseases  of 
the  eyes,  ophthalmia  and  iritis,  diseases  of  the  pelvic  organs  in 
women,  occur  as  evidence  of  the  gonorrheal  infection. 

When  these  infections  are  accompanied  by  the  local  evi- 
dence of  gonorrhea,  which  is  easily  diagnosed,  the  real  cause 
of  the  arthritis  and  other  infections  may  be  suspected.  When, 
however,  an  individual  with  arthritis,  presents  himself  to  a 
physician  for  diagnosis,  unfortunately,  gonorrhea  is  about  the 
last  thing  that  is  suspected  by  the  physician  as  the  cause  of  the 
arthritis ;  and  even  though  the  diagnosis  be  suspected,  and  con- 
firmed, the  treatment  of  these  gonorrheal  secondary  infections 
is  often  far  from  being  satisfactory. 

The  methods  of  diagnosis  must  consist,  first,  in  a  careful 
scrutiny  of  the  history  of  the  case.  This  is  notoriously  a  very 
unsuccessful  method  by  which  the  true  cause  of  the  secondary 
disease  can  be  established,  for  the  reason  that  those  who  have 
had  gonorrhea,  either  forget  the  circumstance,  or  are  not 
willing  to  admit  it ;  and,  again,  many  are  not  aware  that  they 
have  had  a  gonorrheal  infection,  while  they  may  be  at  the  time 
suffering  from  the  ravages  of  that  disease. 

The  methods  of  diagnosis  of  gonococcus  infection  depends, 
first,  upon  the  recovery  of  the  gonococcus.  This  may  occasion- 
ally be  done  from  the  prostate  in  men,  from  the  vagina  and 
urethra  in  women ;  and,  in  certain  cases  of  arthritis,  the  micro- 
organism may  be  obtained  from  the  fluid  in  the  joints.  In 
certain  cases  of  general  infection  it  may  be  obtained  from  the 
blood ;  but  these  findings  rarely  are  made  except  when  the 
patient  is  under  treatment  in  an  institution  where  first-class 
laboratory  facilities  are  at  hand,  and  used. 


GONOCOCCUS    INFECTIONS.  87 

Gonorrheal  fixation  tests  have  lately  been  used  with  some 
success,  although  this  method  is  not  as  yet  considered  as  posi- 
tive a  test  for  gonorrhea,  as  is  the  syphilitic  fixation  test  for 
syphilis. 

The  conditions  which  will  be  considered  under  this  chap- 
ter exclude  the  local  manifestations  of  gonorrhea,  that  is, 
gonorrheal  urethritis.  For  the  symptomatology  and  treatment 
of  this  disease,  the  reader  is  referred  to  a  work  dealing  with 
that  particular  condition. 

It  is  a  well-known  fact  that  a  very  large  percentage  of  the 
blind  in  the  world  become  blind  from  an  ophthalmia  at  birth, 
from  a  gonorrheal  infection  usually  present  in  the  mother.  It 
is  also  a  well-known  fact  that  salpingitis  in  women,  ovaritis, 
and  general  pelvic  inflammation  are  very  frequently  the  result 
of  a  gonorrheal  infection  spreading?  from  the  local  seat  of  the 
disease,  the  urethra  and  the  cervix.  Unfortunately  this  pelvic 
condition,  so  frequent  in  women,  is  often  entirely  innocently 
obtained.  A  man  with  an  uncured  gonorrhea  becomes  mar- 
ried, infects  his  wife,  who,  as  a  rule,  is  never  aware  of  the 
reason  of  her  illness. 

The  treatment  of  both  ophthalmia  and  pelvic  infections  in 
women,  will,  like  the  local  infection  of  gonorrhea,  not  be 
treated  here,  the  one  condition  being  best  dealt  with  by  the 
ophthalmologist,  the  other  by  the  surgeon.  However,  the  prac- 
titioner should  always  bear  in  mind  that  when  a  child  de- 
velops a  conjunctivitis  immediately  after  birth,  it  should  be 
considered  a  gonorrheal  ophthalmia  until  it  is  proven  other- 
wise. If  this  view  is  taken  by  general  practitioners  who  attend 
women  in  labor,  fewer  cases  of  injury  to  the  eye  would  occur. 

Vaginitis  in  young  children  is  a  very  common  disease. 
This  condition  is  very  refractory,  and  the  only  possible  way 
to  treat  it  is  by  isolation  of  the  individual  patient,  and  closing 
the  ward  during  an  outbreak  of  the  disease  until  all  the  chil- 
dren are  perfectly  well,  and  the  room  can  be  cleaned  and 
disinfected. 

Thayer,  Blumer,  and  Cole  have  exhaustively  studied 
gonorrheal  septicemia,  and  have  described  in  detail  a  type 
associated  with  endocarditis,  febrile  cases  resembling  closely 
typhoid  fever,  and  cases  of  general  septicemia  with  multiple 
abscesses  over  the  body. 


88  SPECIFIC    INFECTIONS. 

Osier  reports  one  case,  with  small  abscesses  of  the  pros- 
tate, where  the  subject  died  within  four  days  after  the  initial 
chill:  Cases  of  puerperal  septicemia  consequent  to  gonorrheal 
infection  are  well  known.  The  endocarditis,  the  result  of 
gonorrhea,,  differs  not  at  all  in  its  physical  signs  from  that 
which  occurs  from  any  other  infection,  and  cannot  be  diag- 
nosed except  by  discovering  the  focus  of  infection;  indeed,  as 
much  may  be  said  of  the  fever  resembling  typhoid  fever,  and 
the  deaths  from  septicemia,  and  from  puerperal  septicemia. 
Unless  the  gonococcus  is  discovered  in  a  focal  infection,  the 
true  cause  of  the  disease  may  never  be  known. 

Gonococcus  Arthritis.  Gonorrheal  arthritis  may  occur  dur- 
ing the  acute  attack  of  urethritis,  or  during  a  chronic  urethritis, 
gonorrheal  in  origin ;  also  it  may  occur  when  there  is  no 
urethritis  discoverable,  but  with  the  micro-organism  active  in 
the  prostate  gland. 

The  inflammation  in  arthritis  is  either  periarticular  or 
within  the  joints,  which  rarely  suppurates,  but  become  dis- 
abled and  distorted.  If  an  individual  with  a  gonorrheal 
urethritis  and  prostatitis  develops  an  arthritis,  it  is  very  evi- 
dent that  the  condition  is  gonorrheal  in  origin.  This  usually 
may  be  positively  established  by  withdrawing  liquid  from  the 
joints,  and  examining-  it  for  the  specific  bacteria  of  the  disease. 

The  disease  may  be  polyarthritic  or  monarthritic,  the  latter 
form  being  perhaps  the  more  common.  The  affected  joints 
become  swollen,  extremely  tender,  and  this  persists  in  spite  of 
the  ordinary  treatment  for  arthritis  usually  given.  An  actual 
septicemia  may  occur  from  the  arthritis,  particularly  when  it 
is  polyarthritic. 

Unusual  joints  are  frequently  affected,  such  as  the  sterno- 
clavicular, the  temporal  maxillary,  and  the  sacro-iliac.  Per- 
sistent sore  heels,  the  result  of  a  periostitis,  is  a  very  common 
condition  as  an  after  effect  of  gonorrheal  infection.  When 
an  individual  presents  himself  with  sore  heels,  with  practically 
no  other  symptoms,  an  .i--ray  should  be  taken  to  see  if  the 
periosteum  is  affected,  and  the  proper  treatment  afterward 
instituted. 

TREATMENT. 

The  treatment  of  this  disease  is  very  unsatisfactory,  Be- 
fore any  treatment  is  instituted,  which  promises  success,  the 


INFLUENZA.  89 

existence  of  a  gonorrheal  infection  must  be  established.  This 
may  sometimes  be  done  by  careful  searching  for  local  infec- 
tion, and  cultivating-  the  g-onococcus  from  it.  Sometimes  it 
may  be  established  by  culture  from  the  blood. 

The  treatment  of  the  septicemia  must  be  on  general  lines. 
The  patient  must  be  kept  in  bed,  and  drink  an  abundance  of 
water.  If  there  has  been  a  local  focus  discovered,  that  point 
of  infection  must  certainly  be  cleared  up  before  there  is  much 
hope  of  the  septicemia  disappearing. 

Endocarditis  must  be  treated  as  endocarditis  under  any 
other  conditions.  The  patient  must  be  kept  in  bed  with  an 
ice-bag  over  the  precordia,  until  active  signs  of  fever  and  leu- 
cocytosis  have  disappeared. 

In  arthritic  form  the  joints  must  be  fixed,  and  in  a  position 
in  which  they  will  be  useful  after  the  disease  has  spent  its 
course,  for,  as  noted  above,  many  of  the  cases  of  arthritis 
leave  behind  them  a  deformed  joint. 

Gonorrheal  vaccines  and  gonorrheal  serums  may  be  tried 
in  these  conditions.  In  a  case  of  gonococcal  arthritis,  a  stock 
gonorrheal  vaccine  may  be  used,  with  some  hope  of  success. 
Perhaps  this  is  one  of  the  conditions  in  which  a  vaccine  gives 
best  results. 

In  the  general  conditions,  a  gonorrheal  serum  may  be  used, 
with  the  hope  that  the  antitoxic  properties  of  the  serum  will 
shorten  the  course  of  the  disease. 

In  the  chronic  condition  of  inflammation  of  the  joints,  very 
gentle  massage,  with  hydrotherapy  should  be  used,  with  the 
hope  of  rendering  the  joints  painless  and  supple. 

INFLUENZA. 

Influenza,  la  grippe,  is  due  to  infection  by  Pfeiffer's  bacil- 
lus, a  small,  non-motile  micro-organism  which  usually  lodges  in 
the  respiratory  passages  first,  and  at  this  site  elaborates  absorb- 
able toxins  accountable  for  the  fever,  the  toxemia,  and  the 
systemic  symptoms  of  the  disease.  Influenza,  always  more  or 
less  endemic  in  this  country,  has  appeared  in  two  great  epi- 
demics during  the  last  three  decades — in  1890  and  in  1918. 
Aside  from  these  epidemics,  isolated  cases  have  been  met  with 
from  time  to  time.    The  vast  majority  of  common  colds  are  not 


90  SPECIFIC   INFECTIONS. 

due  to  influenza,  and  the  exact  relation  between  epidemic  in- 
fluenza and  the  epidemic  colds  is  a  moot  point.  It  is,  however. 
evident,  as  proven  by  cultural  methods,  that  most  of  the  epidemic 
colds  are  not  due  to  the  influenza  bacillus.  The  disease  fre- 
quently becomes  pandemic,  and  spreads  over  the  country  in  great 
waves  of  disease.  In  1830-33,  1836-37,  1847-48,  and  in  1888, 
1890  and  1918,  a  scourge  of  the  disease  swept  over  North 
America. 

The  ordinary  attack  of  influenza  begins  with  sudden, 
rather  severe  aching  of  the  whole  body,  severe  headache, 
coryza,  laryngitis  and  bronchitis.  The  exhaustion  is  extreme, 
and  out  of  all  relation  to  the  apparent  seriousness  of  the 
illness ;  it  occurs  suddenly,  and  evidently  the  toxin  elaborated 
by  the  infection  is  formed  in  great  quantities  and  dissemi- 
nated with  extreme  rapidity.  With  the  onset  of  these  symp- 
toms, the  temperature  rises  and  reaches  a  height  of  102°  F. 
(38.8°  C.)  or  103°  F.  (39.4°  C),  and  in  severe  cases  reaching 
as  high  as  105°  F.  (40.5°  C).  This  temperature  remains 
between  102°  and  103°  F.  (38.8°  and  39.4°  C.)  for  five  or  six 
days,  when,  in  the  absence  of  complications,  it  falls  gradually 
to  normal.  During  the  height  of  the  attack  there  is  severe 
and  unproductive  cough,  the  coryza  increases,  the  sore  throat 
becomes  worse,  and  the  aching  of  the  limbs  and  the  headache 
become  almost  unbearable.  As  the  temperature  falls,  the 
severity  of  the  symptoms  diminish,  and  at  the  end  of  about 
ten  days  the  patient  feels  well,  but  is  extremely  exhausted. 
This  extreme  exhaustion  is  one  of  the  peculiarities  of  this 
condition. 

Various  types  of  influenza  are  recognized,  depending 
largely,  or  altogether,  upon  the  effect  of  the  toxin  upon  cer- 
tain sets  of  organs. 

The  respiratory,  gastro-intestinal,  and  nervous  types  are 
those  most  commonly  observed,  and  to  these  may  be  added 
the  typhoid,  circulatory,  renal  and  arthritic  types. 

The  fact  that  more  or  less  frequently  true  influenza  local- 
izes itself  in  these  organs  almost  exclusively,  gives  rise 
to  many  errors  in  diagnosis,  especially  during  an  epidemic  of 
the  infection.  All  of  us,  and  particularly  the  overworked  gen- 
eral practitioner,  in  the  hurry  and  stress  of  his  duties,  is  very 
jikeiy  to  lose  sight  of  the  fact  that  while  attacks  of  influenza 


INFLUENZA.  91 

make  up  the  greater  number  of  cases  he  sees,  other  diseases 
can,  and  do  occur,  during  such  times.  The  consequence  is 
that  enough  attention  is  not  given  to  attempts  to  differentiate 
influenza  from  other  diseases,  and  typhoid  fever,  pneumonia, 
meningitis,  and  so  on,  are  frequently  overlooked  in  their 
incipient  stages,  and  are  treated  as  influenza,  much  to  the 
detriment  of  the  patient. 

Respiratory  types  of  influenza  are  by  all  odds  the  most 
common,  and  in  such  instances  the  symptoms  of  bronchitis, 
laryngitis,  tonsillitis  and  coryza  dominate  the  clinical  picture. 
In  this  type  bronchopneumonia  quite  frequently  supervenes 
as  the  direct  result  of  invasion  by  the  influenza  bacillus.  This 
influenzal  manifestation  or  complication  is  very  frequently 
overlooked,  but  the  association  of  continued  fever,  leuco- 
cytosis,  unusual  dyspnea,  and  characteristic  physical  signs 
relating  to  the  lungs  make  the  diagnosis  certain. 

Nervous  symptoms  during  an  attack  of  influenza  some- 
times dominate  the  picture.  Here  extreme  headache,  actual 
neuritis,  and  signs  of  meningitis  are  the  symptoms  most  in 
evidence. 

Gastro-intestinal  symptoms  such  as  vomiting,  diarrhea,  and 
more  or  less  localized  abdominal  pain  are  certainly  very  fre- 
quent during  an  epidemic  of  influenza.  Whether  they  are 
simply  complications  of  influenza  or  due  to  bacteria  other 
than  influenza  bacilli,  is  difficult  to  prove. 

Typhoid  forms  of  the  grip  also  exist,  and  such  types  are  due 
to  an  unusually  severe  toxemia.  Here  the  greatest  danger  is 
of  considering  every  typhoid-like  case  influenza,  instead  of 
making  careful  blood  examinations  for  the  Widal  reaction, 
and  searching  for  typhoid  spots,  to  exclude  true  typhoid 
fever. 

It  is  an  almost  impossible  task  to  isolate  cases  of  influenza 
during  an  epidemic,  but  children  and  aged  persons  should 
certainly  be  kept  out  of  contact  with  know^n  cases  of  the  dis- 
ease whenever  possible.  As  a  general  measure  of  prophy- 
laxis the  sputum  should  be  burned  whenever  practicable. 

TREATMENT. 

There  is  no  specific  drug  for  influenza,  and  there  are  no 
specific  measures  to  be  observed  in  the  management  of  the 


92  SPECIFIC    INFECTIONS. 

infection.  Ever}-  case,  even  the  lightest,  hoAvever,  should  be 
put  at  rest  in  a  well-ventilated  room,  and  the  patient  pro- 
tected by  proper  bed-clothing.  In  every  instance  the  patient 
should  maintain  this  rest  until  all  of  the  acute  symptoms  have 
passed.  Drugs  such  as  the  salicylates,  especially  phenol 
salicylate  (salol)  and  acetyl  salicylic  acid  (aspirin)  should  be 
used  for  the  relief  of  the  muscular  pains  and  the  headache. 
The  bowels  should  be  kept  active  with  calomel,  followed  by 
some  mild  saline  cathartic,  such  as  citrate  of  potassium  or 
sodium  phosphate.  Active  purging  is  weakening  and  not 
desirable.  A  mixture  of  citrate  of  potassium  and  sweet  spirits 
of  nitre  is  useful  as  a  sudorific. 

Severe  headache  is  frequently  relieved  by  caffein  (the 
alkaloid)  and  sodium  bromid.  Two  grains  (0.13  Gm.)  of 
the  former  and  15  to  20  grains  (0.972  to  1.3  Gms.)  of  the  lat- 
ter every  three  hours  is  an  appropriate  dose  for  an  adult.  In 
the  face  of  a  persistent  neuralgic  headache,  and  when  there 
is  tenderness  over  the  sinuses,  a  sinusitis  should  be  suspected 
and  looked  for.  Indeed,  most  of  the  attacks  of  headache 
which  persist  are  due  to  swelling  of  the  lining  membrane  of 
the  sinuses.  By  no  means  always,  and,  indeed,  very  seldom, 
is  the  sinusitis  suppurating.  Occasionally  there  remains  for 
many  days  after  the  ordinary  headache  has  disappeared  a 
periodic  pain  which  comes  on  early  in  the  morning  and  dis- 
appears by  mid-day  or  earlier.  This  periodic  headache  is 
relieved  and  apparently  cured  by  large  doses  of  quinin.  Ten 
grains  (0.65  Gm.)  of  quinin  given  on  retiring  will  usually 
cause  this  annoying  S3^mptom  entirely  to  disappear  within  the 
course  of  a  few  days. 

The  bronchitis  is  relieved  by  the  general  measures  sug- 
gested ;  it  may  be  further  relieved  by  the  use  of  potassium 
citrate  and  chlorid  of  ammonium.  If  the  cough  is  frequent 
and  unproductive,  paregoric,  codein  or  heroin  will  give  much 
relief,  and  often  converts  a  very  distressing  condition  into  one 
which  is  mild.  Care,  of  course,  must  be  taken  to  avoid  nar- 
cotizing the  patient. 

Otitis  media  must  always  be  borne  in  mind  as  a  possible 
complication,  and  the  ears  should  always  be  examined,  espe- 
cially in  children.     Any  bulging  of  the  drum  calls  for  imme 
diate  puncture  of  the  drum-membrane.     Mild  attacks  of  mid- 


INFLUENZA.  93 

<31e-ear  disease  can  be  aborted  by  the  instillation  of  a  5 
per  cent,  phenol  solution  in  glycerin;  or  atropin,  Yi^o  grain 
(0.0004  Gm.),  in  the  form  of  a  hypodermic  tablet,  may  be 
dropped  into  the  canal  and  dissolved  in  situ  with  a  few  drops 
of  warm  water.  The  ear  should  be  covered  with  a  pad  of 
cotton. 

Laryngitis  may  be  relieved  by  bromid  of  potassium  and 
citrate  of  potassium  internally,  and  by  inhalation  of  steam, 
plain  or  medicated  with  compound  tincture  of  benzoin. 

Pneumonia  must  be  treated  as  pneumonia  of  any  other 
type.     (See  p.  28.) 

Vomiting  can  be  controlled  by  the  withdrawal  of  food, 
and,  if  it  persists,  with  10  grains  (0.65  Gm.)  of  bismuth  sub- 
nitrate  in  lime-water.  The  following  prescription  will  be 
found  effective : 

B  Bismuthi   subnitratis   16   (246.8  gr.). 

Pulv.  acacise 20  (308.6  gr.) . 

Liquor  calcis q.  s.  ad  120  (4  fE) . 

M.     S. :   One  teaspoonful  (4  mils)  every  two  or  three 
hours. 

A  mustard  plaster  to  the  epigastrium  is  often  comforting. 
If  the  bismuth  is  not  effective,  a  powder  such  as  the  following 
may  be  used : 

I^  Codeine    0.16  (2^  gr.). 

Cerii  oxalatis    2.00  (40  gr.). 

Cocainse  hydrochloridi O.OOSl    (^s  gr.). 

Ft.  pulv.  no.  j. 

S. :    One  powder  every  three  hours. 

Care  must  be  taken  not  to  give  enough  of  this  powder  to 
produce  a  toxic  effect. 

Diarrhea.  This  demands  also  withdrawal  of  food  and, 
perhaps,  fractional  doses  of  calomel,  ever};-  half-hour,  followed 
by  a  saline,  until  the  offending  material  is  cleared  from  tiie 
bowel.  This  may  be  followed,  if  necessary,  by  a  formula  sucn 
as  the  following: 

B  Bismuthi  subnitratis    16  (246.8  gr.). 

Phenolis  salicylatis   8   (123.4  gr.). 

Misturae  cretae  compositi  120  (4  fS). 

M.     S. :     One    teaspoonful    (4    mils)    every     two  01 
three  hours. 


94  SPECIFIC   INFECTIONS. 

Neuritis.  The  pain  of  this  disturbing  condition  is  best 
relieved  by  fixation  of  the  limb,  if  one  of  the  distal  nerves  be 
affected ;  by  the  application  of  heat  in  the  form  of  a  hot-water 
bottle  or  an  electric  pad ;  and  sometimes  by  the  administra- 
tion of  acid  acetyl  salicylic  in  5-grain  (0.325  Gm.)  doses, 
acetanilid  in  5-grain  (0.325  Gm.)  doses,  and  acetphenetidin 
(phenacetin)  in  the  same  dosage,  the  use  of  which  may  give 
relief  when  the  salicylates  fail.  These  drugs  must  not  be 
continued  more  than  twenty-four  hours  consecutively,  for 
fear  of  disintegrating  the  blood,  which  may  follow  prolonged 
use. 

Meningitis.  This  may  show  all  the  symptoms  of  meningitis 
due  to  other  micro-organisms.  The  diagnosis  depends  upon 
the  discovery  of  influenza  bacilli  in  the  spinal  fluid.  The  pa- 
tient should  be  at  rest,  should  have  the  spinal  canal  tapped  at 
least  every  twenty-four  hours.  Torrey  has  reported  a  case  of 
this  fatal  form  of  influenza  which  ended  in  recovery  after  the 
spinal  canal  had  been  tapped  fourteen  times. 

Waldstein  has  perfected  a  serum  for  the  treatment  of 
influenza  which  is  said  to  have  some  curative  value.  Torrey 
did  not  find  any  particular  relief  after  its  use  in  his  case. 

To  combat  active  nervous  unrest,  bromid  of  potassium 
in  full  doses  is  of  value.  To  this  may  be  added  chloral 
hydrate. 

Cardiac  Symptoms.  Disturbances  of  the  cardiovascular 
system  should  be  treated  by  absolute  rest.  If  an  actual  endo- 
carditis develops,  this  rest  should  be  prolonged  into  weeks,  in 
order  that  the  local  inflammation  of  the  valves  may  be  as  near 
at  an  end  as  possible  before  the  stress  put  upon  the  heart  is 
increased  by  allowing  the  patient  to  move  about.  Ice-bags 
to  the  precordia  in  the  early  stages  and  the  avoidance  of  digi- 
talis are  necessary. 

Urinary  Inflammation  is  correctly  treated  by  the  adminis- 
tration of  large  quantities  of  water.  Hexamethylenamin  is 
?;iseful,  if  the  pelvis  of  the  kidney  or  the  bladder  are  infected, 
but*  stimulating  diuretics  should  not  be  advised.  If  there  is 
a  complicating  nephritis,  such  drugs  but  increase  the  renal 
inflammation.  Strychnin  sulphate,  %o  grain  (0.002  Gm.) 
three  times  a  day,  or  tincture  of  nux  vomica,  20  drops  (1.25 
mils)  three  times  a  day,  is  of  great  value. 


CEREBROSPINAL   FEVER.  95 

The  typhoid  forms  of  la  grippe  must  be  treated  by  rest,  an 
abundance  of  good  food  and  strychnin.  If  the  fever  is  high, 
cold  sponging  should  be  used. 

Convalescence  is  often  prolonged.  The  patient  is  w^eak, 
as  evidenced  by  exhaustion  on  the  least  exertion,  by  breath- 
lessness,  and  by  cardiac  palpitation.  If  the  attack  has  been 
one  of  severity,  the  patient  should  be  kept  away  from  his 
work  for  a  prolonged  period,  and  when  he  does  return  should 
not  work  the  full  number  of  hours  at  a  time. 


CEREBROSPINAL   FEVER. 

This  condition,  also  known  as  epidemic  meningitis  and  as 
spotted  fever,  is  a  true  meningitis  due  to  infection  by  the 
Diplococcus  intracelhdaris  meningitidis. 

The  disease  is  transmissible  from  man  to  man,  from  man 
to  lower  animals,  and  from  animal  to  animal  through  several 
generations. 

Flexner  and  his  co-workers  have  shown  that  the  disease 
can  be  transmitted  from  man  to  monkey  by  means  of  the 
nasal  discharge,  and  they  believe  that  the  portal  of  entry 
through  which  human  being's  become  infected  is  the  nasal 
mucous  membrane. 

The  attack  usually  begins  suddenly,  with  high  fever,  in- 
tense headache,  and,  as  early  symptoms,  cervical  rigidity, 
stiff  back,  Kernig's  sign,  the  Babinski  reflex,  and  Brudzen- 
ski's  sign  are  of  prime  importance.  Herpes  frequently  occurs, 
and  there  is  always  a  polymorphonuclear  leucocytosis.  The 
patient  rapidly  grows  worse,  and  in  about  75  per  cent,  of  the 
cases  succumbs  to  the  disease,  if  proper  treatment  is  not 
instituted  at  once.  Many  variations  of  this  ordinary  picture 
occur.  The  most  important  diagnostic  sign  is  the  condition 
of  the  spinal  fluid,  the  presence  of  the  meningococci  in  it  is  an 
unmistakable  pathognomonic  sign. 

The  fluid  can  be  obtained  only  by  puncture  of  the  spinal 
canal,  which  simple  procedure  should  be  done  early,  and  in 
every  case  of  suspected  meningitis.  Only  by  the  character 
of  the  spinal  fluid  can  the  type  of  the  meningeal  inflammation 
be  ascertained.  Indeed,  I  tliink  that  spinal  puncture  may  be 
regarded  not  only  as  the  sole  means  of  making  a  positive 


gS  SPECIFIC    INFECTIONS. 

diagnosis,  but  here,  as  in  meningitis  of  any  type,  as  one  of  the 
most  important  therapeutic  measures. 

The  operation  is  simple,  and  every  physician  should  be 
able  to  perform  it.  The  skin  of  the  back  should  be  cleansed 
along  the  spinal  column.  lodin  should  then  be  applied  over 
the  line  cf  the  spinal  processes  and  about  2  inches  (5.08  cm.) 
on  each  side,  reaching  from  the  last  thoracic  vertebra  to  the 
sacrum.  If  the  patient  is  a  child  or  a  nervous  adult,  novo- 
cain or  cocain  should  be  injected  into  the  skin  and  deep  into 
the  tissues.  I  believe  this  lessens  the  pain  of  entering  the 
spinal  puncture  needle.  A  spinal  puncture  needle  should  be 
cf  small  caliber,  provided  with  a  short,  beveled  tip,  and  fitted 
Avith  an  accurately  ground  obturator.  The  needle  is  steri- 
lized, the  hands  of  the  operator  are  made  as  sterile  as  pos- 
sible, and,  by  choice,  sterile  gloves  are  used.  The  patient 
should  have  the  spine  curved  anteriorly  as  much  as  possible. 
The  second,  third  and  fourth,  lumbar  spinal  processes  should 
be  identified,  the  last  named  lying  approximately  on  the  level 
of  the  highest  point  of  the  crests  of  the  ilia.  The  needle  then 
held  firmly  is  plunged  in  the  median  line  straight  forward 
between  the  second  and  third,  or  the  third  and  fourth  lumbar 
spinous  process.  It  will  enter  from  2  to  3  inches  (5.08  to  7.62 
cm.),  depending  upon  the  thickness  of  the  tissues  of  the  back. 
As  the  needle  enters  the  canal  the  membranes  will  be  felt  to 
give  way  suddenly.  The  obturator  is  then  withdrawn  and  the 
fluid  flows  freely  from  the  needle  end.  If  no  fluid  comes,  most 
likely  the  needle  is  not  in  the  canal,  or  it  is  an  interspace 
too  low.  The  dry  tap  is  usually  due  to  faulty  technic, 
although  there  are  instances  where  the  fluid  is  purulent  and 
too  thick  to  flow,  and  others  in  which  there  is  little  fluid. 
Every  dry  tap  made  by  the  author  has  been  due  to 
faulty  technic,  as  proved  by  the  fact  that  a  successful  tap 
has  been  made  shortly  after,  either  by  himself  or  by  another 
operator. 

Sdfnetimes  it  is  well  to  go  into  the  canal  from  a  lateral 
position.  In  this  event  the  same  site  should  be  selected,  but 
rne  needle  is  to  be  started  al)out  1  inch  (2.54  cm.)  to  one  side 
or  other  of  the  midline,  and  then  pushed  slightly  upward  and 
inward.  T'his  gives  more  pain  than  when  the  needle  is 
inserted  in  midline. 


CEREBROSPINAL    FEVER.  97 

In  the  vast  majority  of  cases  the  fluid  of  cerebrospinal 
meningitis  is  cloudy.  It  should  be  examined  at  once  by  the 
microscope.  If  the  cloudiness  is  due  to  polymorphonuclear 
leucocytes,  the  specific  treatment  should  at  once  be  given.  If 
it  is  practicable  to  stain  a  smear  of  the  fluid,  the  presence  of 
the  diplococci  within  the  cells  will  be  seen,  and  the  diagnosis 
will  be  certain.  But  in  any  cloudy  meningeal  fluid  the  specific 
serum  should  be  given  after  the  first  puncture,  even  if  there 
is  no  opportunity  of  making  a  bacteriologic  diagnosis  at  the 
time.  A  bacteriologic  diagnosis,  however,  should  be  made 
before  it  is  time  to  give  a  second  dose  of  serum. 

TREATMENT. 

The  specific  treatment  is  Flexner's  antimeningococcic 
serum.  This  should  be  on  hand  at  the  time  of  tapping  every 
suspicious  case,  and  should  be  given  through  the  same  needle 
with  which  the  canal  is  drained.  It  is  wise  to  use  the  aspira- 
tion needle  which  comes  with  the  serum.  From  30  to  40  mils 
(1  to  1.3  fj)  of  spinal  fluid  are  withdrawn;  then,  by  the 
gravity  method  a  little  less  serum  is  allowed  to  flow  into  the 
canal  than  has  been  removed.  The  aspiration  and  introduc- 
tion of  serum  should  be  repeated  every  twelve  to  twenty-four 
hours.  The  fluid,  after  the  second  tapping,  is  likelv  to  be 
much  clearer,  and  to  contain  fewer  bacteria  than  that  first 
withdrawn,  if  the  case  is  a  favorable  one. 

The  reason  that  the  serum  treatment  is  fully  described  is 
that,  like  diphtheria  antitoxin,  the  earlier  it  is  given  the  bet- 
ter the  results  of  the  case.  To  wait  a  number  of  hours  until 
a  microscopic  examination  could  be  made,  might  mean  the 
dift'erence  between  life  and  death. 

It  is  certain  that  the  disease  in  question  is  communicable 
from  one  individual  to  another,  usually  through  the  secretions 
of  the  mouth  and  nose,  and,  in  view  of  this,  careful  prophy- 
lactic measures  are  to  be  observed.  This  makes  it  wise 
always  to  disinfect  such  discharges.  The  cases  should  be 
isolated.  In  epidemics  the  cases  seem  to  be  more  ^•irulently 
transmissible  than  in  sporadic  cases,  but  the  latter  are  about 
as  readily  communicated  from  the  sick  to  the  well  as  are  cases 
of  croupous  pneumonia. 


98  SPECIFIC    INFECTIONS. 

Food  is  important — milk,  eggs  and  cereals  should  be  taken 
in  as.  large  quantities  as  the  patient  can  stand. 

Hexamethylenamin  should  be  given  in  doses  of  5  grains 
(0.324  Gm.)  every  three  hours,  a  careful  watch  being  kept 
meanwhile  on  the  urinary  secretion,  for  this  drug  irritates  the 
urinary  tract,  and  is  to  be  discontinued  when  symptoms  of 
irritation  supervene.  Morphin  or  opium  in  some  form  should 
be  given  for  the  pain  and  restlessness,  or  the  patient  may  be 
placed  in  a  warm  bath.  Bromid  of  potassium  or  sodium  is 
of  value,  if  given  in  20-grain  (1.3  Gms.)  doses  every  two 
hours.  This  may  be  combined  with  chloral  hydrate  in  10- 
grain  (0.65  Gm.)  doses. 

The  fever  can  be  controlled  by  sponging  or  by  tubbing. 

Tapping  the  spinal  canal  alone  is  of  use  as  a  tolerably 
specific  therapeutic  measure,  and  the  operation  should  be 
repeated  daily  so  long  as  the  symptoms  either  remain  sta- 
tionary or  become  aggravated. 

The  postfebrile  emaciation  should  be  combated  by  mas- 
sage, rest,  fresh  air  and  good  food. 

Arthritic  symptoms  are  best  treated  by  massage,  and  by 
the  injection  of  the  serum  into  the  affected  joint. 

TETANUS. 

The  cause  of  tetanus  is  an  initial  wound  in  which  the 
bacillus  of  tetanus  becomes  implanted,  and  without  such  a 
wound  the  bacillus  does  not  find  lodgment  in  the  human  body. 
Any  wound,  varying  from  a  mere  abrasion  to  a  severe  lacera- 
tion, may  become  infected  with  the  tetanus  bacillus.  The 
bacillus  has  its  habitat  particularly  in  the  dirt  of  the  street, 
in  and  about  stable  ground,  or  around  pastures  where  horses 
have  fed.  The  micro-organism  is  anerobic,  and,  therefore, 
wounds  which  quickly  heal  over  after  having  been  infected 
with  the  tetanus  bacillus  are  those  most  likely  to  give  rise 
to  the  disease. 

Unfortunately,  cases  of  tetanus  have  followed  vaccination 
against  smallpox,  but  in  no  instance  has  a  contamination  of 
the  vaccine  itself  been  conclusively  proved;  and  in  more  fre- 
quent instances,  three  of  which  came  under  the  writer's  notice 
during  the  last  year  at  the  Episcopal  Hospital,  the  tetanus 


TETANUS.  -99 

bacillus  had  become  implanted  on  the  ulcer  resulting-  from  the 
vaccination,  entirely  independent  of  the  vaccine  virus  itself. 

The  disease  begins  first  with  stiffness  of  the  jaws,  and 
sometimes  stiffness  of  the  neck.  This  rapidly  develops  into 
a  tetanic  spasm  of  the  muscles,  and  this  spasm  quickly  affects 
all  of  the  muscles  of  the  body;  first  the  muscles  of  the  back, 
and  afterward  the  muscles  of  the  abdomen  and  limbs.  The 
muscles  of  the  face  are  particularly  aft'ected.  Inability  to 
open  the  mouth,  or  "lock-jaw,"  occurs,  and  during  an  active 
spasm  the  face  muscles  are  drawn  up  into  a  grin-like  position, 
the  so-called  "sardonic  grin." 

Tetanus  neonatorum  is  simply  tetanus  occurring-  in  the  new- 
born infant,  in  which  the  bacillus  gets  its  lodgment  in  an 
improperly  dressed  umbilical  cord. 

TREATMENT. 

Perhaps  the  most  important  point  in  the  treatment  of 
tetanus  is  the  treatment  of  the  initial  wound,  and  the  prophy- 
lactic use  of  antitetanic  serum,  which  is  of  particular  moment 
in  wounds  received  from  fire-crackers  and  blank  cartridges, 
which  are  so  commonly  used  on  the  Fourth  of  July.  The 
wound  should  be  thoroughly  opened  and  cauterized,  either 
with  an  actual  cautery  or  with  nitric  acid,  and  then  it  should 
l)e  kept  open,  in  order  that  any  bacillus  with  lodgment  in  the 
wound  may  be  exposed  to  the  air,  which  is  fatal  to  its  life. 
The  individual  should  then  at  once  receive  from  5000  to 
10,000  units  of  antitetanic  serum  into  the  muscles.  In  this 
way  tetanus  can  practically  be  overcome. 

Until  very  recently  the  mortality  of  developed  tetanus  was 
extremely  high,  and,  while  still  high,  there  is  an  appreciable 
diminution  in  its  fatality.  As  soon  as  a  patient  with 
developed  tetanus  is  seen  he  should  be  given  3000  units  of 
antitetanic  serum  into  the  spinal  canal,  5000  units  into  the 
muscles,  preferably  the  muscles  of  the  buttock  or  back,  and 
10,000  units  into  the  vein.  This  may  be  repeated  from  twelve 
to  twenty-four  hours  after,  according  to  the  necessity  of  the 
case. 

To  quote  Keen's  masterly  treatise  on  "The  Treatment  of 
War  Wounds,"  one  should  "expect  tetanus  in  all  wounds  and 


100  SPECIFIC    INFECTIONS. 

prevent  its  onset,"  and  the  observation  of  this  rule,  originally 
insisted  upon  by  Gibson,  has  practically  caused  the  disappear- 
ance of  lockjaw  in  the  armies  now  engaged  in  conflict  on 
the  Continent.  "This  conquest  of  tetanus  is  one  of  the  notable 
victories  of  the  war." 

In  an  article  by  Matthias  Nicholl,  read  before  the  Asso- 
ciation of  American  Physicians,  in  1915,  the  intraspinal  admin- 
istration is  considered  of  particular  importance,  and  he  reports 
20  cases  which  are  treated  as  they  occur  in  or  about  the  city 
of  New  York,  with  three  deaths.  This  is  an  unusually  lovv' 
mortality  for  developed  tetanus.  His  method  is  to  give  3000 
to  5000  units  into  th^  spinal  canal,  10,000  units  into  the  vein, 
and  repetition  of  the  intraspinal  dose  in  twenty-four  hours, 
and  a  subcutaneous  dose  of  10,000  units  thirty-six  hours  later. 

The  ordinary  methods  of  treatment,  of  course,  must  be 
carried  out  in  these  cases  of  tetanus.  The  patient  is  kept  in 
a  darkened  room,  free  from  drafts,  and  from  visitors.  He 
must  not  be  disturbed.  Even  the  physician  must  disturb  him 
as  little  as  practicable.  The  reason  for  this  is  that  frequently 
a  patient  may  be  lying  in  a  relatively  comfortable  position 
when  he  has  tetanus,  and  the  least  disturbance  will  throw  him 
into  a  violent  tetanic  spasm. 

He  should  be  given  large  doses  of  bromid  of  potassium 
and  chloral,  the  chloral  in  lO-grain  (0.6  Gm.)  doses  every 
three  hours,  and  bromid  in  20-grain  (1.3  Gm.)  doses  every 
three  hours,  which  can  be  kept  up  for  three  or  four  days. 

The  stiffness  of  the  jaw  remains  a  considerable  length  of 
time  after  the  subsidence  of  the  symptoms  in  other  portions 
of  the  body. 

Meltzer,  some  years  ago,  suggested  the  injection  into  the 
spinal  canal  of  a  25  per  cent,  solution  of  magnesium  sulphate, 
1  mil  (16  m.)  of  this  solution  being  injected  for  every  twenty- 
five  pounds  (11.33  Kg.)  of  weight  of  the  patient.  The  writer 
has  used  this,  and  while  it  will  certainly  control  the  spasm, 
in  the  majority  of  cases  this  appeared  to  him  as  a  rather 
dangerous  method,  as  some  of  the  patients  have  died  from 
respiratory  failure,  apparently  the  result  of  the  injection. 
Even  in  developed  tetanus  it  is  wise  to  excise  the  wound,  and 
to  use  the  open  method  of  treatment  of  the  consequent  wound. 


GLANDERS.  101 


GLANDERS. 


Glanders  is  a  communicable  disease,  due  to  the  Bacillus 
mallei,  and  contracted  by  man  from  horses.  If  the  disease 
affects  the  nostrils  it  is  called  glanders,  and  if  it  affects  the 
skin  it  is  termed  farcy. 

Glanders  has  been  frequently  contracted  in  the  laboratory 
by  workers  using-  the  Bacillus  mallei  for  experimental  purposes. 
It  exists  in  man  in  the  acute  and  chronic  form.  At  the  height 
of  the  infection,  there  is  redness,  swelling  of  the  affected  areas, 
and  lymphang-itis.  There  is  malaise,  followed  by  fever,  and  the 
individual  becomes  acutely  ill,  as  he  does  of  any  other  acute 
infection.  Shortly  after  the  infection,  the  nose  becomes  in- 
volved, the  granulomata  break  down,  and  there  is  a  discharge 
from  the  nostrils.  According  to  Osier,  generalized  papules 
occur  and  have  been  mistaken  for  smallpox.  The  lymph- 
glands  are  enlarged,  and  pneumonia  may  supervene.  These 
cases  are  practically  all  fatal.  The  diagnosis  can  only  be  made 
certain  by  cultivation  of  the  causative  bacillus  from  the  lesions. 

Chronic  glanders  is  a  variety  of  the  disease  which  mas- 
querades in  the  form  of  a  chronic  coryza.  Chronic  osteomye- 
litis has  been  described  as  the  result  of  infection  by  the  Bacillus 
mallei,  also  glandular  nodules  may  occur  in  almost  any  of  the 
internal  tissues. 

The  diagnosis  of  these  cases  may  sometimes  be  made  by 
the  use  of  mallein  used  in  the  same  manner  as  tuberculin  is 
used  for  diagnostic  purposes,  after  the  method  of  von  Pirquet. 

TREATMENT. 

When  a  case  of  glanders  is  diagnosed,  the  most  important 
measure  is  to  disinfect  all  the  discharges  from  the  nose  or 
from  any  of  the  suppurating  areas.  There  is  no  specific  treat- 
ment. The  treatment  must  be  based  on  general  lines,  such  as 
rest,  elimination  by  administration  of  abundance  of  water,  by 
resort  to  the  use  of  digitalis  if  the  heart  fails,  and  by  an  abun- 
dance of  fresh  air  and  good  food. 

Acute  forms  of  glanders  are  almost  always  fatal,  and  many 
of  the  cases  of  chronic  glanders  end  in  death. 


102  SPECIFIC    INFECTIONS. 

ANTHRAX. 

Anthrax  is  an  infectious  disease  of  domestic  animals,  com- 
municable to  man  by  inoculation,  inhalation,  or  ingestion  of 
the  specific  bacterium  of  the  disorder,  the  Bacillus  anthracis 
found  in  the  blood,  tissues,  and  local  lesions  of  infected  sub^ 
jects. 

Synonymous  terms  for  the  disease  are  referable  in 
certain  instances  to  the  characteristic  external  signs  of  the 
infection  (malignant  pustule;  malignant  edema;  erysipelatous 
anthrax)  ;  in  others  to  prominent  clinical  features,  such  as 
splenic  enlargement  and  pyrexia  (splenic  fever)  ;  and  in  still 
others  to  occupational  predisposition  (wool-sorters'  disease). 

Human  anthrax  is  confined  almost  exclusively  to  those 
whose  work  brings  them  in  close  contact  with  wool  and  hides, 
and  the  vast  majority  of  cases  occur  in  butchers,  tanners,  wool- 
sorters,  and  drovers. 

Malignant  pustule  and  malignant  edema  are  the  two  types 
of  external  anthrax,  acquired  by  inoculation  through  an  abras- 
ion, scratch,  or  cut  in  the  skin,  and  in  this  common  variety  of 
the  disease  the  chief  objective  symptoms  relate  to  a  small  red 
papule  with  an  inflamed  indurated  base,  rapidly  developing 
into  a  necrotic  pustular  mass  attended  by  violent  inflamma- 
tory edema  and  considerable  adenitis  of  the  neighboring 
lymph-glands.  Exceptionally,  a  rapidly  spreading  circum- 
scribed edema,  with  no  definite  pustule,  constitutes  the  initial 
lesion,  in  the  event  of  which  death  from  overwhelming  sepsis 
is  to  be  anticipated. 

Two  forms,  the  pulmonary  and  the  gastro-intestinal,  are 
included  in  the  relatively  less  common  variety  of  internal  an- 
thrax, resulting  from  inhalation  of  the  germs  or  from  eating 
the  flesh  of  infected  animals.  Both  of  these  varieties  of  an- 
thrax are  dominated  by  the  constitutional  symptoms  of  septi- 
cemia, with  a  clinical  picture  of  either  acute  diffuse  bronchitis 
or  bronchopneumonia  in  the  first,  and  with  evidences  of  violent 
gastro-intestinal  disturbance  in  the  latter.  These  types  of  in- 
ternal anthrax  carry  an  unfavorable  prognosis,  the  outlook 
being  particularly  bad  in  gastro-intestinal  cases. 

External  anthrax  offers  no  great  difliculty  in  diagnosis,  and 
the  characteristic  appearance  of  the  local  lesion  charged  with 


ANTHRAX.  103 

the  specific  bacillus  is  proof  positive  of  the  nature  of  the  affec- 
tion. In  the  internal  variety,  however,  the  problem  is  harder 
to  solve,  and,  while  the  patient's  occupation  may  afford  a  clue, 
such  evidence  is  largely  intangible,  and  should  be  corroborated 
by  the  discovery  of  the  anthrax  bacillus  in  the  blood-stream. 

TREATMENT. 

It  is  hardly  necessary  to  state  that  extirpation  and  thor- 
ough cauterization  of  the  local  lesion  is  to  be  done  without 
delay  in  every  case  of  malignant  pustule.  This  is  accomplished 
most  effectually  by  the  actual  cautery,  for  excision  with  the 
knife  is  more  than  likely  to  leave  unremoved  bits  of  infected 
tissue  and,  furthermore,  may  disseminate  the  bacteria  through 
the  circulation.  If  the  knife  be  used,  it  should  be  supple- 
mented by  the  application  of  the  hot  iron,  carbolic  acid,  or 
some  similar  corrosive  liquid,  in  order  to  insure  a  clean  and 
aseptic  wound  at  the  site  of  the  primary  sore. 

Hypodermic  injections  of  a  %o  aqueous-etheral  solution  of 
carbolic  acid  under  and  around  the  wound  and  the  application 
of  a  compress  wet  with  the  same  solution  is  advised  by  Bell. 
Subsequently  the  local  treatment  consists  of  cleansing  with  a 
%ooo  mercuric  chlorid  solution  and  the  application  of  tincture 
of  iodin  to  the  lesion  and  to  the  surrounding  zone  of  inflam- 
mation. In  favorable  cases  this  routine  carried  out  for  a  fort- 
night or  three  weeks  results  in  healing  of  the  ulcerated  focus, 
with  but  slight  scarring,  considering  the  nature  of  the  infection 
and  the  necrosis  thereby  caused. 

In  addition  to  the  foregoing  methods  of  caring  for  the  local 
lesion,  all  types  of  anthrax  should  undergo  treatment  with 
Sclava's  antianthrax  serum,  the  routine  use  of  which  in  Italy 
has  within  recent  years  reduced  the  mortality  from  this  dis- 
ease from  24.1  per  cent.,  to  6.1  per  cent.,  the  present  figure 
(Cavaille).  By  preference  the  immune  serum  is  given  in- 
travenously, in  initial  doses  of  from  80  to  100  mils  (21 J/^  to 
27  fo),  although  some  prefer  the  intramuscular  technic. 
Favorable  results  also  have  attended  the  use  of  stock  vaccines 
made  of  the  BacilUis  pyocyanens,  and  of  salvarsan  in  0.3  Gm. 
(4.6  gr.)  intravenous  injections. 

The  management  of  the  coincident  septicemia,  the  domi- 
nant clinical  feature  of  many  cases  of  anthrax,  differs  in  no 


104  SPECIFIC    INFECTIONS. 

essential  from  that  of  other  grave  septic  disorders,  the  treat- 
ment of  which  is  considered  elsewhere,  and  therefore  does  not 
warrant  further  discussion  in  this  place.     (See  p.  48.) 

Finally,  the  suppression  and  spread  of  anthrax  demands 
close  attention,  and  the  details  of  such  preventive  measures 
have  to  do  with  the  rigid  inspection  and  quarantine  of  live 
stock ;  the  disinfection  of  hides,  wool,  hair,  hoofs,  horns,  bones, 
and  glue  stock,  and  the  similar  care  of  vehicles,,  yards,  and 
abattoirs;  and  the  sanitary  regulations  observed  in  slaughter- 
ing, relating  not  alone  to  this  process,  but  also  to  the  butchers 
and  fellow-workmen.  For  an  interesting  account  of  the  pro- 
phylactic measures,  enforced  by  this  and  other  countries,  the 
reader  is  referred  to  the  United  States  Government  publication 
on  the  subject.  (Bulletin  of  the  U.  S.  Bureau  of  Labor  Statis- 
tics :  "Anthrax  as  an  Occupational  Disease,"  Washington, 
1917.) 

WHOOPING-COUGH. 

The  bacillus  described  by  Bordet  and  Gengou  is  probably 
the  cause  of  whooping-cough.  The  certainty  of  this  being 
the  fact  is  of  great  importance,  both  from  a  diagnostic  and 
therapeutic  standpoint,  because,  as  will  be  seen,  suspensions 
of  these  live  bacilli  may  be  used  for  diagnostic  purposes,  and 
the  killed  bacilli  or  vaccine  for  treatment.  If  they  are  not  the 
cause,  both  the  treatment  and  diagnosis  by  use  of  suspension 
vaccines  are,  of  course,  based  on  wrong  premises.  In  the 
present  state  of  our  knowledge  they  may  be  considered  as 
the  active  cause  of  the  disease. 

The  disease  is  transmissible,  probably  directly  from  one 
individual  to  another,  inasmuch  as  the  infected  individual  is 
able  to  disseminate  the  contagion  several  feet.  One  writer 
says  5  feet  is  the  distance  it  can  be  communicated.  It  is 
probable  that  the  bacilli,  when  deposited  in  any  place  where 
they  are  not  killed  by  air  and  sunlight,  survive  for  a  period 
of  time,  and  become  the  immediate  source  of  transmission. 

The  prophylaxis,  therefore,  consists  of  keeping  infected 
individuals  (children)  out  of  school,  and  from  public  gather- 
ings, and  attention  to  the  destruction  of  all  material  they 
expectorate   or   vomit.      The    habit   of   allowing   children    to 


WHOOPING-COUGH.  105 

expectorate  on  the  street,  and  to  permit  them  to  expel  this 
expectoration  with  the  vomit  on  the  street,  is  pernicious. 

If  children  suffering'  from  the  disease  are  taken  into  a  train, 
or  go  in  the  street,  there  should  be  taken  along  some  sort  of 
receptacle  in  which  this  mucus  ran  be  collected  and  destroyed. 

Vaccination  against  whooping--cough  has  been  tried  with 
some  success.  Children  who  are  exposed  to  whooping-cough 
should  be  regularly  vaccinated  with  a  good  stock  vaccine. 

The  symptoms  of  the  disease  are  well  known.  There  is  at 
first  a  catarrhal  stage,  in  which  the  patient  appears  to  have  an 
ordinary  bronchitis,  but  even  in  this  stage  there  is  a  tendency 
for  the  cough  to  be  rather  paroxysmal,  and  to  occur  more  fre- 
quently at  night.  In  a  week  or  ten  days  the  cough  becomes 
distinctly  paroxysmal,  the  "spells"  coming  on  at  intervals  vary- 
ing from  fifteen  minutes  to  two  or  three  hours.  As  a  rule^  the 
paroxysms  are  worse  at  night,  and  when  the  individual  is  ex- 
cited or  cries.  The  paroxysm  is  characterized  by  several  short 
expiratory  coughs,  followed  by  a  long-drawn  inspiration  of 
high-pitched  character — the  so-called  "whoop."  Sometimes 
the  paroxysm  is  accompanied  by  so  much  embarrassment  of 
breathing  that  there  is  marked  cyanosis,  and  occasionally 
bleeding  from  the  nose  and  petechia  under  the  skin.  In  very 
severe  paroxysms  the  child  may  go  into  convulsions,  or  an 
attack  of  syncope  may  occur.  A  paroxysm  is  very  rarely 
fatal,  except  in  young  infants.  When  death  occurs  in  whoop- 
ing-cough it  is  usually  the  result  of  one  of  the  complications, 
pneumonia  being  the  most  frequent  cause  of  death. 

The  diagnosis  during  the  height  of  the  disease  is  not  diffi- 
cult, the  paroxysmal  attacks  being  present  in  few  other  con- 
ditions. Care  must  be  taken,  however,  that  a  mediastinal 
growth,  such  as  enlarged  bronchial  glands,  is  not  mistaken 
for  whooping'-cough.  This  condition  lacks  the  history  of  a 
catarrhal  stage,  lasts  much  longer,  and  dullness  under  the 
sternum  and  along  the  vertebral  column  can  be  made  out  by 
careful  physical  examination.  Cases  of  tetany  might  also  be 
mistaken  for  whooping-cough.  In  the  early  stages  of  whoop- 
ing-cough, examination  of  the  blood  is  of  the  greatest  value. 
There  is  a  leucocytosis  often  of  high  degree.  The  author  has 
seen  one  of  32,000,  with  a  predominant  increase  of  lympho- 
cytes.    An  agglutination  test  also  is  said  to  be  of  value,  the 


106  SPECIFIC   INFECTIONS. 

blood  of  the  patient  agglutinating  the  fresh  culture  of  Bordet's 
bacillus  exactly  as  the  blood  of  a  typhoid  patient  agglutinates 
the  culture  of  typhoid  bacillus. 

TREATMENT, 

The  patient  should  be  kept  constantly  in  the  fresh  air, 
either  in  rooms  with  the  windows  open  or  out-of-doors,  de- 
pending upon  the  condition  of  the  weather.  On  clear  days 
the  child  should  sleep  out-of-doors,  and  when  in  the  room  the 
windows  should  be  widely  open.  Violent  exercise,  crying, 
and  laughing  are  apt  to  precipitate  a  paroxysm,  hence  the 
patient  should  not  take  part  in  rough  games,  and  should  be 
as  free  from  excitement  as  possible. 

Young  infants  should  be  carefully  watched.  In  these  and 
in  other  frail  individuals  there  is  danger  from  the  paroxysm 
itself,  and  care  should  be  taken  to  protect  the  patient  by  lift- 
ing it  in  the  arms,  supporting  the  head,  and  otherwise  giving 
support  to  its  body  muscles  and  chest.  Kilmer's  croup  band- 
age is  said  to  be  of  some  value,  particularly  in  young  children. 
Rurah  describes  it  as  follows : 

"A  stockinette  band,  similar  to  those  used  under  plaster 
jackets,  is  applied  to  the  body  from  the  axillae  to  the  pubes, 
and  two  shoulder  straps  are  used  to  keep  it  from  slipping. 
On  this  stockinette  a  width  of  silk  elastic  is  sewed,  so  that  it 
goes  around  the  abdomen,  and  entirely  covers  it.  It  should 
be  pinned  slightly  on  the  stretch,  and  then  sewed  on,  so  as  to 
keep  it  from  curling." 

The  protected  finger  may  be  used  to  remove  the  mucus 
from  the  fauces,  which  often  seems  to  impede  the  respiration  ; 
this  use  of  the  nurse's  hand  also  seems  to  be  of  value,  because 
the  jaw  is  pushed  down,  and  it  should  also  be  pushed  forward. 

Vaccines.  The  treatment  of  whooping-cough  by  vaccines 
of  the  Bordet  bacillus  is  on  trial.  In  the  few  cases  the  writer 
has  used  it,  it  has  not  been  of  signal  value,  but  favorable 
reports  have  been  made  as  to  the  efficacy  of  vaccine  therapy 
in  the  condition,  and  it  is  a  wise  thing  to  use  a  stock  vaccine 
of  reliable  make  in  every  case  of  whooping-cough. 

The  various  powders  and  whooping-cough  cures  which  are 
in  the  market  are  mentioned  only  to  be  condemned.  Various 
local  sprays  have  been  tried,  but  their  varied  character  and 


WHOOPING-COUGH.  107 

number  prove  that  none  of  them  are  specific,  just  as  the  same 
holds  for  internal  medication. 

Food.  The  frequent  vomiting  inseparable  from  whooping- 
cough  often  causes  much  emaciation.  To  overcome  this  lack 
of  food  it  is  important  to  give  small  amounts  of  food  fre- 
quently, rather  than  large  amounts  at  one  time.  The  diet 
should  consist  largely  of  milk.  If  the  food  is  vomited,  try  to 
persuade  the  child  to  eat  immediately  after  the  vomiting,  for 
in  this  way  nourishment  can  be  kept  up.  Of  all  things,  the 
stomach  must  be  protected  from  overdosing  by  drugs. 

Internal  Medicines.  The  one  drug  which  has  seemed  of 
some  value  to  the  writer  is  belladonna. 

This  may  be  given  in  the  form  of  a  tincture.  The  best 
method  is  to  begin  with  3  to  5  drops  (0.2  to  0.3  mil)  of  the  tinc- 
ture every  three  hours,  increasing  the  dose  1  drop  daily;  that 
is  on  the  first  day  give  5  drops  (0.3  mil)  in  water  every 
three  hours,  on  the  second  6  drops  (0.4  mil)  ever}^  three 
hours,  and  so  increase  until  the  child  gets  a  physiologic  effect, 
as  evidenced  by  flushing  of  the  face  and  dilatation  of  the 
pupils.  The  dose  should  be  kept  at  that  point  or  increased 
later. 

The  next  most  useful  drug  is  bromid  of  potassium.  In 
many  cases  full  doses  of  this  most  useful  remedy,  5  grains 
(0.32  Gm.),  every  three  hours  for  a  child  3  years  old,  will  les- 
sen both  the  number  and  the  severity  of  the  paroxysms.  Care 
must  be  taken  in  the  use  of  large  doses  of  this  drug  that  the 
little  patient  is  not  too  badly  narcotized.  The  writer  has 
seen  children  badly  poisoned  with  the  dose  recommended,  but 
nevertheless,  the  drug  is  of  so  much  value  that  it  should  be 
used,  always  with  due  care. 

Chloral  may  be  added  to  the  mixture  of  bromid  of  potas- 
sium, in  doses  of  2  to  3  grains  (0.13  to  0.19  Gm.). 

Bromoform  and  antipyrin  have  both  been  highly  recom- 
mended, but  there  is  a  distinct  danger  in  both  of  these  rem- 
edies.    The  writer  has  rarely  used  them. 

If  there  is  much  bronchitis,  both  chlorid  of  ammonia  and 
citrate  of  potassium  can  be  added  to  the  bromid  mixture  with 
great  benefit. 

When  pneumonia  develops,  it  should  be  treated  with  just 
as  much  detail  as  it  is  treated  under  any  other  conditions. 


108  SPECIFIC   INFECTIONS. 

Frequently  the  paroxysms  are  so  severe  that  there  is  dis- 
tinct dilatation  of  the  heart.  In  these  cases,  digitalis  used  in 
full  enough  doses  to  tone  up  the  heart  muscle  is  of  distinct 
value.  After  the  attack  is  over,  many  of  the  children  are  weak 
and  anemic.  Attention  to  their  general  health,  and,  above  all, 
fresh  air  and  good  food  is  important.  If  they  are  anemic,  iron 
in  some  form  is  of  distinct  value. 

Tuberculosis  is  a  frequent  sequel,  probably  as  an  exacer- 
bation of  an  old  lesion.  Great  care  must  be  taken  to  detect 
this  lesion,  and  not  to  comfort  one's  self  with  the  futile 
thought  that  the  condition  is  only  weakness  following  the 
attack. 

ROCKY    MOUNTAIN    SPOTTED    FEVER. 

This  di'Sease  occurs  in  the  valleys  of  the  Rocky  Mountains 
in  Idaho  and  in  Montana;  it  has  been  found  also  in  the  valleys 
of  Nevada  and  AVyoming. 

The  cause  of  the  disease  is  not  known,  but  it  has  been 
proved  by  Ricketts  and  King  that  it  is  spread  by  means  of  a 
tick,  the  Dermaccntor  occidentalis.  These  authors  have  trans- 
mitted the  disease  to  animals  by  means  of  bites  of  these  ticks ; 
they  also  found  that  the  ova  and  young  of  the  infected  ticks 
contain  the  infective  material.  "A  certain  percentage  of  the 
female  ticks,  which  have  acquired  the  disease  as  a  consequence 
of  feeding  on  animals,  the  latter  having  been  infected  by  other 
ticks,  transmit  the  disease  to  their  offspring  through  the  eggs. 
The  new  generation,  during  the  process  of  feeding,  transfer 
the  virus  to  certain  of  the  susceptible  small  wild  animals 
(ground  squirrel,  rock  squirrel,  chipmunks,  ground  hogs,  and, 
perhaps,  others),  and  this  may  take  place  either  during  the 
larval,  nymphal  or  adult  stage ;  hence  at  various  times  of  the 
year.  During  the  infection  of  the  wild  animals  it  is  required 
that  hitherto  normal  ticks,  either  as  larvse,  nymphs  or  adults, 
acquire  the  disease  by  feeding  simultaneously  with,  or  shortly 
after,  the  feeding  of  the  infected  ticks. 

"There  is  a  short  period  of  malaise,  followed  usually  by 
a  well-marked  chill.  These  chills  may  be  repeated  through- 
out the  course  of  the  attack.  At  the  beginning  there  is  severe 
aching  of   the   bones   and   muscles,   pains   in   the   joints,   and 


ROCKY   MOUNTAIN    SPOTTED    FEVER.  109 

severe  headache.  Constipation  is  the  rule.  The  skin  is  dry; 
the  tongue  is  coated  and  sordes  appear  early,  and  the  case  has 
the  appearance,  except  for  the  chill,  of  a  typhoid  in  its  begin- 
ning. The  temperature  rather  rapidly  develops,  and  soon 
reaches  102°  or  103°  F.  (38.8°  or  39.4°  C.)  on  the  third  or 
fourth  day.  It  may  go  much  higher,  reaching  even  107°  F, 
(41.6°  C).  There  is  usually  a  slight  evening  increase  and 
morning  decrease.  When  recovery  occurs,  the  temperature 
falls  by  lysis. 

"The  most  characteristic  part  of  the  disease  is  seen  upon 
the  skin.  From  the  second  to  the  fifth  day  after  the  chill  a 
macular  rash  appears  around  the  ankles  and  upon  the  w^rists, 
and  then  extends  over  the  entire  body,  sometimes  in  twelve 
hours.  More  usually,  however,  it  takes  a  longer  time.  A 
desquamation,  best  seen  on  the  soles  of  the  feet  and  the  palms 
of  the  hands,  occurs  during  the  second  week  of  the  disease. 
Occasionally  there  is  jaundice.  In  severe  cases  the  patients 
become  delirious,  and  pass  into  a  typhoid  state.  However, 
there  is  no  sign  of  meningitis.  The  pulse  is  rapid,  and  out  of 
proportion  to  the  temperature.  The  blood  is  only  slightly 
changed,  the  erythrocytes  being  normal,  and  the  leucoc}^tes 
ranging  from  12,000  to  13,000.  Except  for  constipation,  there 
is  no  unusual  sign  of  disturbance  of  the  digestion.  The  urine 
frequently  shows  the  signs  of  a  severe  febrile  condition, 
albumin  and  casts. 

TREATMENT. 

"The  treatment  is  entirely  symptomatic.  However,  the 
prophylaxis  is  an  important  part.  Persons  whose  business 
calls  them  into  these  valleys  in  the  spring  time  should  be 
warned  of  a  possibility  of  infection,  and  should  protect  them- 
selves against  the  bite  of  ticks  in  everv  possible  manner,  par- 
ticularly by  protecting  the  feet  and  hands.  General  principles 
should  govern  the  treatment.  The  patient  should  be  in  a  cool, 
well-ventilated  room ;  the  diet  should  be  soft  and  properly 
regulated.  Cold  sponging  for  the  fever,  with  morphin  or 
other  opiate,  if  the  patient  becomes  extremely  restless.  As 
a  tonic  afterward,  the  patient  may  be  given  nux  vomica  and 
srentian." 


110  SPECIFIC    INFECTIONS. 

EPIDEMIC    PAROTITIS    (Mumps). 

Epidemic  parotitis  is  a  transmissible  disease  which  is 
highly  coiitagious. 

The  cause  of  the  contagion  is  not  known.  The  disease  is 
characterized  by  a  period  of  incubation  lasting  from  one  week 
to  two  weeks,  and  by  a  period  of  invasion  of  shorter  duration, 
one  or  two  days,  in  which  the  temperature  rises  to  100°  or 
101°  F.  {37.7°  or  38.3°  C).  Then  the  parotid  gland  on  one 
side  gradually  enlarges  in  front  of  and  underneath  the  ear, 
pushing  the  lobe  of  the  ear  forward,  and  extending  backward 
under  the  sternomastoid  muscle.  In  from  two  to  three  days 
the  gland  on  the  opposite  side  enlarges,  and  then  the  child 
presents  the  picture  of  a  swelling  surrounding  his  neck,  com- 
posed of  enlarged  glands  and  indurated  tissue.  Other  salivary 
glands  may  also  become  enlarged  and  painful.  Sometimes  the 
submaxillary  and  sublingual  glands  are  the  first  to  become 
affected,  though  this  is  not  the  rule.  The  lachrymal  gland 
also  may  become  affected.  There  are  cases  on  record  in  whic!i 
the  symptoms  have  resembled  those  of  an  acute  pancreatitis, 
indicating  that  the  pancreas  has  taken  part  in  this  disease. 

During  the  height  of  the  disease  the  temperature  rises  to 
102°  or  even  to  104°  F.  (38.8°  to  40°  C),  but  remaining  at 
this  height  for  only  a  short  time.  At  the  end  of  a  week 
the  temperature  subsides,  and  the  individual  becomes  con- 
valescent. 

The  disease  as  seen  in  the  ordinary  practice  of  medicine 
is  of  very  slight  importance,  but  when  it  occurs  in  communi- 
ties, such  as  soldiers  in  barracks  or  children  in  orphan  homes, 
it  is  a  more  serious  disease,  and  many  fatal  cases  are  reported. 
In  these  fatal  cases  there  often  is  a  typhoid  state,  resembling 
typhoid  fever,  or  nervous  symptoms  may  supervene,  delirium, 
and  even  convulsions. 

Suppuration  of  the  gland  is  very  rare,  gangrene  of  the 
gland  has  been  reported.  After  the  subsidence  of  the  swell- 
ing in  the  gland,  and  the  child  has  become  convalescent,  one 
or  the  other  testicle  is  apt  to  be  affected.  The  testicle  be- 
comes hard,  swollen  and  painful,  and  remains  so  for  several 
days.  The  cause  of  this  orchitis  is  not  known ;  it  has  been 
suggested,  however,  that  it  is  due  to  an  autogenous  infection, 


ACUTE   POLIOMYELITIS.  HI 

the  individual  transferring  the  virus  by  means  of  the  hands 
to  the  penis,  and  from  there  the  infection  travels  to  the 
testicles. 

In  females  the  breasts  sometimes  enlarge,  and  there  are 
cases  on  record  where  the  ovary  has  become  affected. 

TREATMENT. 

Every  case  of  mumps  should  be  kept  in  bed  during  the 
height  of  the  disease.  This  particularly  applies  to  males, 
because  it  appears  that  those  individuals  w^ho  are  up  and  about 
during  or  shortly  after  an  attack  are  very  much  more  likely 
to  develop  an  orchitis ;  this  orchitis  being  of  more  or  less  seri- 
ous import,  atrophy  of  the  testicles  occurring  rather  rapidly, 
and  when  both  testicles  are  afifected,  of  course,  this  atrophy 
presents  the  serious  sequela  of  inability  to  procreate. 

The  pain  in  the  salivary  glands  may  be  relieved  by  hot 
fomentations,  by  hot  poultices,  by  a  hot  solution  of  saturated 
magnesium  sulphate.  On  the  other  hand,  cold,  to  certain 
individuals,  is  more  grateful  than  heat.  If  fever  is  very  high, 
the  use  of  citrate  of  potassium,  and  sweet  spirits  of  nitre,  10 
grains  (0.6  Gm.)  of  the  former,  to  15  drops  (1  mil)  of 
the  latter,  sometimes  appears  to  do  good.  If  the  fever  con- 
tinues high,  cold  sponging  may  be  used  to  allay  this  symptom. 
The  bowels  should  be  kept  moved  by  a  mild  laxative,  and  a 
soft  diet  should  be  advised.  For  the  orchitis,  applications  of 
heat  or  cold,  as  the  case  may  be,  and  use  of  a,  suspensory  of 
some  sort  while  the  testicle  is  swollen,  will  give  a  great  deal 
of  comfort. 

If  there  is  much  depression,  if  the  individual  is  suffering 
from  the  toxemia,  a  stimulant  should  be  used  in  the  form  of 
ammonia,  caffein,  and  strychnin.  Large  amounts  of  water 
should  be  given  to  combat  the  toxemia. 


ACUTE    POLIOMYELITIS    (Infantile  Paralysis). 

This  is  an  acute  communicable  disease,  due  to  a  virus 
located  in  the  central  nervous  system,  and  in  the  discharges 
from  the  nose,  throat  and  intestine.  Colmer,  of  Long  Island, 
suggested  in  1841  that  poliomyelitis  is  a  communicable  dis- 


112  SPECIFIC    INFECTIONS. 

ease ;  and  AVickman,  of  Stockholm,  proved  this  to  be  true  by 
clinical  methods  and  careful  observation. 

It  remained  for  the  laboratories  to  put  the  question  of 
communicability  beyond  doubt,  by  the  fact  that  they  com- 
municated the  disease  to  monkeys  by  injecting-  into  them  por- 
tions of  the  spinal  cord  and  brain  of  human  beings  dead  of 
the  disease.  Later  Flexner  and  Noguchi  isolated  the  germ 
of  this  infection  and  cultivated  it. 

In  the  sick,  the  virus  is  located  in  the  central  nervous  sys- 
tem, and  in  the  discharges  from  the  nose,  throat  and  intestine. 
In  the  well,  the  virus  unfortunately  cannot  be  identified  by 
ordinary  laboratory  methods,  and  therefore  we  lack  a  lab- 
oratory diagnosis  in  the  so-called  abortive  cases,  such  as  we 
have  in  diphtheria  and  typhoid  fever. 

Wickman  described  eight  types  of  this  disease : 

1.  The  spinal  poliomyelitis  type. 

2.  The  form  resembling  Landry's  paralysis. 

3.  The  bulbar  or  pontone  type. 

4.  The  encephalitic. 

5.  The  ataxic. 

6.  The  polyneuritic. 

7.  The  meningitic. 

8.  The  abortive. 

From  the  standpoint  of  prophylaxis  and  treatment,  the 
abortive  type  is  by  all  odds  the  most  important.  The  diag- 
nosis is  difficult,  as  will  be  shown  later,  but  a  probable  diag- 
nosis can  be  made  in  practically  all  cases.  In  a  suspected 
case  every  care  should  be  taken  that  a  diagnosis  is  made  when 
possible.     For  practical  purposes,  the  important  types  are : 

1.  The  abortive  type. 

2.  The  meningitic  type. 

3.  The  common  paralytic  type. 

As  yet  the  virus  has  not  been  discovered  in  the  blood  of 
those  sick  with  the  disease,  although  in  one  case  a  bedbug 
which  had  fed  upon  the  blood  of  an  infected  monkey  was 
shown  to  harbor  the  virus,  but  these  bedbugs  did  not  convey 
the  disease  to  other  monkeys  by  biting  them.  The  virus  enters 
the  healthy  human  being  probably  always  through  the  nose 
and  throat.  The  virus  resists  the  greatest  heat  of  summer,  and 
it  also  resists  drying.  It  may  be  modified  by  daylight,  and  it 
may  be  easily  destroyed  by  bright  sunlight. 


RHEUMATIC    FEVER.  113 

The  foregoing  facts  being  admitted,  there  can  be  no  ques- 
tion but  that  the  disease  should  be  regarded  as  a  specific  in- 
fection affecting  the  gray  substance  of  the  spinal  cord.  Yet. 
inasmuch  as  nervous  symptoms  dominate  the  clinical  picture, 
it  seems  wiser  to  consider  in  detail  this  type  of  poliomyelitis 
in  connection  with  nervous  diseases,  just  as  the  symptoms- 
complex  of  tabes  and  paresis  are  discussed  under  this  group 
of  affections,  rather  than  with  luetic  infections.  The  reader  is, 
therefore,  referred  elsewhere  for  a  full  consideration  of  the 
various  phases  of  acute  poliomyelitis,  its  treatment,  and  gen- 
eral management.    (See  section  on  "Nervous  Diseases,"  p.  670.) 

RHEUMATIC    FEVER. 

Rheumatic  fever  is  an  acute  infectious  disease,  charac- 
terized by  fever,  drenching  sweats,  multiple  arthritis,  anemia, 
and  a  tendency  toward  inflammation  of  the  endocardium,  with 
complete  recovery  of  the  joint  condition. 

Poynton  and  Payne  have  described  a  micro-organism,  the 
Micrococcus  rlienmaticiis,  which  they  believe  is  the  specific 
cause  of  this  acute  disease.  This  observation,  however,  has 
not  been  fully  confirmed  by  all  laboratory  workers.  Because 
of  the  loose  way  the  name  of  rheumatism  is  given  to  joint 
aft'ections,  it  will  perhaps  be  wise  to  attempt  briefl}^  to 
differentiate  rheumatic  fever  from  other  conditions  causing 
arthritis. 

The  disease  usually  begins  suddenly,  often  with  a  chill 
followed  by  high  fever,  but  occasionally  the  onset  is  insidious, 
being  preceded  for  a  longer  or  shorter  time  by  general  ill 
health,  by  anemia,  and  other  signs  of  weakness.  In  the 
beginning  there  is  often  sore  throat,  aching  in  the  limbs,  and 
slight  fever  before  the  acute  symptoms  occur.  The  arthritis 
is  one  of  the  most  characteristic  symptoms  of  the  disease.  It 
is  multiple;  one  joint,  usually  one  of  the  larger  joints,  the 
wrist,  elboAv,  or  knee,  becomes  painful,  swollen  and  red,  and 
liquid  develops  in  or  around  the  joint.  The  pain  in  these 
inflamed  joints  is  extreme,  and  the  individual  cries  out  with 
pain  on  the  least  attempt  at  voluntarv  movement,  or,  indeed, 
when  the  joint  is  moved  by  the   nurse.      Frequently   several 


114  SPECIFIC   INFECTIONS. 

joints  are  affected  at  one  time.  Sometimes  one  joint  is  inflamed, 
becomes  relatively  better,  then  a  second  joint  is  implicated; 
this  becoijies  better,  and  the  third  joint  is  affected,  and  so  on, 
until  practically  every  joint  in  the  body  may  suft'er.  An 
anemia  rapidly  develops,  and  a  leucocytosis  is  usually  pres- 
ent. Severe  drenching  sweats  at  the  height  of  the  fever  are 
very  common.  The  pain  in  the  swollen  and  inflamed  joints 
is  often  so  great  that  the  patient  voluntarily  immobilizes  him- 
self, and  complains  bitterly,  even  when  the  bed  is  moved. 
The  temperature  range  is  high,  102°  and  104°  F.  (38.9°  to 
40°  C.),  and  it  may  rise  even  in  an  ordinary  case  to  105°  F. 
(40.6°  C). 

The  complications  of  the  disease  are  extremely  important. 
Of  the  greatest  importance  is  inflammation  of  a  heart  valve. 
An  endocarditis  develops  in  a  large  majority  of  the  cases  of 
true  rheumatic  fever.  The  valve  most  frequently  affected  is 
the  mitral,  although  an  aortic  valve  may  be  implicated.  Peri- 
carditis may  occur,  as  well  as  endocarditis,  either  independ- 
ently or  as  a  part  of  the  serous  membrane  infection.  This 
pericardial  inflammation  is  characterized  sometimes  only  by 
an  audible  friction  murmur;  at  other  times  there  is  pain  in 
the  region  of  the  heart,  sometimes  so  severe  that  it  may  be 
transmitted  to  the  abdomen,  and  mistaken  for  appendicitis. 
Occasionally  the  physical  signs  appear  most  rapidly,  within 
an  hour  from  the  time  a  careful  examination  has  been  made, 
and  no  friction  rub  or  pain  elicited,  and  a  second  examination 
may  show  a  loud  friction  murmur.  If  an  effusion  occurs,  the 
murmur  may  disappear  as  quickly  as  it  appears. 

Hyperpyrexia.  The  patient  may  become  wildly  delirious, 
even  maniacal,  and  the  temperature  rise  to  105°  or  106°  F. 
(40.6°  or  41.1°  C.)  ;  he  may  die  in  this  state  from  excessive 
fever. 

Where  the  infection  is  very  severe,  the  endocarditis  and 
pericarditis  may  be  accompanied  by  an  actual  pneumonia  and 
pleuritis.     Pulmonary  complications  may  also  occur  alone. 

Of  the  nervous  symptoms,  delirium  is  perhaps  the  most 
common.  Chorea  occurs  probably  as  part  of  the  manifesta- 
tion of  the  rheumatic  infection  in  the  spinal  cord  and  brain, 
and  in  the  meninges. 


RHEUMATIC   FEVER.  115 

One  often  sees  this  combination :  first,  a  slight  attack  of 
chorea,  which  may  advance  to  quite  a  severe  attack,  and  this 
is  either  preceded  or  accompanied  by  tonsillitis ;  then  the 
cvirious  fibrous  nodules  occur;  finally,  an  endocarditis.  The 
writer  has  notes  of  such  a  case,  in  which  tonsillitis,  chorea, 
fibrous  nodules,  a  slight  arthritis,  and  a  very  severe  endo- 
carditis occurred,  the  child  losing  her  life  in  the  course  of 
three  or  four  years  from  the  endocardial  infection. 

Notwithstanding  the  occurrence  of  such  cases  as  these, 
the  exact  relationship  of  rheumatism  and  chorea  is  still  not 
accurately  established. 

Cerebral  Rheumatism.  This  name  is  given  to  a  condition 
characterized  by  wild  delirium,  coma,  and  sometimes  convulsions 
and  hyperpyrexia.  Osier  states  that  in  certain  cases  of  this 
sort  seen  by  him  he  considers  the  salicylates  which  had  been 
given  were  the  cause  of  the  untoward  symptoms.  This  so- 
called  cerebral  rheumatism  may  occur  in  the  midst  of  the 
disease,  or  in  the  very  beginning. 

Rheumatic  nodules  are  small  bodies  which  occur  along 
the  sheaths  of  the  tendons,  usually  about  the  elbows,  hands 
and  wrists.  They  are  painless,  movable,  and,  according  to 
Payne,  are  truly  inflammatory  objects,  and  are  not  com- 
posed of  fibrous  tissue. 

Pneumonia  and  pleurisy  both  occur.  There  is  nothing 
peculiar  in  the  symptoms  of  these  conditions  when  they  com- 
plicate rheumatism,  but  probably  v\^hen  they  occur  during  the 
attack  of  rheumatism  are  part  and  parcel  of  this  infection. 
They  are  most  commonly  associated  with  the  cases  which 
also  have  endocarditis  as  a  complication. 

Erythema,  frequently  in  the  circinate  form,  commonly 
develops  during  an  attack  of  rheumatism. 

Erythema  nodosa  is  characterized  by  nodular  infiltration, 
usually  upon  the  calves  and  shins,  the  nodules  being  raised, 
dark  red  or  purplish,  and  extremely  painful.  The  exact  rela- 
tion of  erythema  nodosa  to  true  rheumatism  is  not  known. 

Mild  Forms  of  Rheumatism.  Perhaps  as  important  as  any 
other  rheumatic  infection  are  the  very  mild  forms,  where  the 
arthritis  is  extremely  slight,  and  often  a  symptom  which  does 
not  call  the  attention  of  the  patient  to  his  condition.  The 
so-called  "growing  pains"  of  the  laity  are  unquestionably,  in 


116  SPECIFIC    INFECTIONS. 

certain  instances,  true  rheumatism,  as  proved  by  the  fact  that 
these  so-called  "growing-  pains"  are  very  frequently  accom- 
panied by  endocarditis  and  other  affections,  which  frequently 
complicate  true  rheumatism ;  therefore,  when  a  child  com- 
plains of  vague  pains  in  his  joints,  careful  search  should  be 
made  of  the  throat,  of  the  heart,  and  of  the  extremities,  to  be 
sure  that  one  is  not  dealing-  with  a  true  rheumatic  infection, 
and  also  to  be  sure  that  he  is  not  overlooking-  the  endocarditis 
so  often  incident  to  this  condition. 

As  stated  in  the  beginning  of  this  section,  the  dififerentia- 
tion  of  rheumatism  from  other  arthritic  conditions  is  so  badly 
done,  except  where  careful  study  of  the  case  is  made,  that 
perhaps  it  will  be  wise  to  take  into  consideration  very  briefly 
the  differentiation  of  these  various  conditions. 

First,  to  deal  with  so-called  muscular  rheumatism.  Al- 
most without  exception,  muscular  rheumatism  is  a  form  of 
m3^algia  due  to  infections  other  than  rheumatism.  Rarely  are 
these  muscular  affections  accompanied  by  any  of  the  symp- 
toms or  complications  common  in  true  rheumatism.  There  is 
no  arthritis,  no  endocarditis,  and  often  no  fever. 

Multiple  Secondary  Arthritis.  Secondary  arthritis  occurs 
as  a  result  of  many  infections,  such  as  gonorrhea  and  syphilis, 
and  is  often  the  result  of  a  toxin  elaborated  by  the  poisons 
of  scarlet  fever  and  diphtheria.  The  great  and  important 
point  in  the  diagnosis  and  differentiation  of  these  conditions 
from  rheumatism  is  to  search  for  the  causative  factor.  Too 
frequently  a  polyarthritic  condition  of  gonorrheal  origin  is 
treated  as  rheumatism,  until  the  joints  are  deformed,  and 
until  much  harm  has  been  done.  If  the  case  had  been  care- 
fully studied,  and  the  cause,  gonorrhea,  found,  doubtless  the 
individual  would  have  gotten  well  without  deformed  joints. 
Rheumatism  is  often  mistaken  for  a  traumatism  when  it 
chances  to  be  localized  to  one  joint,  especially  the  knee-joint, 
or  in  one  of  the  extremities.  Of  course,  the  differentiation 
here  depends  entirely  upon  the  history  as  to  whether  the 
individual  has,  or  has  not,  suffered  an  injury. 

Arthritis  deformans  is  frequently  mistaken  for  rheuma- 
tism. In  this  condition,  in  the  ordinary  form,  the  individual 
develops  pain,  stiffness,  and  deformity  of  various  joints,  often 
and  usually  either  the  joints  in  the  hands  or  the  feet.     When 


RHEUMATIC   FEVER.  117 

the  condition  is  acute,  it  resembles  in  many  particulars  acute 
rheumatic  fever,  but  the  joints  soon  become  deformed,  are 
fixed,  and  remain  in  that  condition  for  months,  and  perhaps 
habitually.  This  is  an  entirely  different  picture  from  the 
acute  onset  or  acute  condition  of  the  joints  in  rheumatic  fever. 

The  harm  w^hich  has  been  done  in  these  cases  of  rheuma- 
toid arthritis  or  arthritis  deformans  is  that  the  focus  of  infec- 
tion, which  is  the  cause  of  these  destructive  arthritic  condi- 
tions, has  not  been  searched  for,  and  the  patient  becomes  a 
chronic  invalid  before  the  investigation  is  made.  Again,  the 
arthritis  deformans  patient  is  put  on  all  sorts  of  diet  entirely 
unsuited  to  his  condition. 

Gout  is  a  condition  which  may  be  mistaken  for  rheuma- 
tism. Usually,  in  the  typical  cases,  gout  is  sudden  in  its 
onset,  affecting  by  predilection  the  second  joint  of  the  great 
toe ;  there  is  sudden  fever,  sudden  swelling  and  redness  of 
the  joint,  and  the  patient  is  extremely  ill  for  two,  three,  or 
four  days,  and  then  rather  abruptly  becomes  convalescent, 
with  a  rapid  disappearance  of  the  arthritic  signs.  In  chronic 
gout  there  is,  almost  without  exception,  a  deposit  of  the 
biurate  of  soda  in  and  about  the  joint,  and  these  deposits  may 
be  found  upon  many  of  the  cartilaginous  parts,  such  as  the 
pinna  of  the  ear.  This,  again,  is  a  condition  which  is  entirely 
different  from  true  rheumatism. 

Epiphysitis,  of  septic  origin,  is  unfortunately  frequently 
mistaken  for  rheumatism.  When  the  epiphyseal  extremities 
of  a  joint  are  affected  in  a  child,  and  particularly  when  only 
one  joint  is  aff'ected,  one's  suspicion  should  always  be  aroused. 
The  affected  part  should  be  carefully  .r-rayed,  put  at  rest  at 
once,  and  immediate  surgical  interference  made,  when  the 
condition  seems  to  be  in  the  bone,  and  not  in  the  joint  itself. 
Many  children  have  lost  their  lives  by  considering  this  inflam- 
mation of  the  bone  itself  a  true  rheumatism,  until  destructior 
of  the  bone  has  occurred. 

Osteomyelitis,  another  condition,  affecting  other  portions 
of  the  bone,  is  also  mistaken  for  rheumatism.  The  author  has 
seen  deaths  from  it,  the  result  of  treating  it  as  rheumatism 
for  weeks,  and  finally  necessitating  serious  operation. 

In  all  these  cases,  if  the  observer  remembers  that  true 
rheumatism    is    an    acute    infection,    beginning    suddenlv.    as 


118  SPECIFIC    INFECTIONS. 

many  other  acute  infections  do,  often  with  sore  throat,  high 
fever,  anemia  and  leucocytosis,  and  that  the  joints  are  affected 
early,  usually  as  a  multiple  arthritis,  almost  without  excep- 
tion one  can  come  to  a  quick  decision,  and  differentiate  the 
arthritic  conditions  of  which  I  have  spoken  from  rheumatism 
without  much  trouble. 

Of  course,  occasions  arise  in  some  cases  where  one  is  in 
grave  doubt  as  to  the  true  cause  of  the  joint  trouble.  When 
one  is  in  such  doubt,  however,  he  should  be  careful  to  give 
the  advantage  toward  the  more  serious  condition. 

TREATMENT. 

The  lightest  case  of  rheumatic  fever  should  be  at  rest  in 
bed,  for  the  reason  that  not  only  may  the  joint  condition  be 
limited  by  the  rest,  but  that,  even  in  the  mildest  cases,  endo- 
carditis is  likely  to  occur,  and  when  this  takes  place  it  can  be 
treated  properly  only  by  the  insistence  on  complete  rest  from 
the  very  beginning  of  the  illness. 

When  practicable,  the  affected  joint  should  be  fixed  in 
some  sort  of  a  splint,  in  order  thus  to  prevent  movement,  and 
possibly  to  limit  the  inflammation,  and  also  to  relieve  the 
pain  from  which  the  patient  suffers.  Applications  to  the 
joints  of  ointment  of  menthyl  salicylate,  or  of  a  saturated 
solution  of  magnesium  sulphate,  or  some  warm  application, 
such  as  an  electric  pad  or  hot-water  bag,  give  comfort  to  the 
patient. 

If  the  joint  is  surrounded  by  large  pads  of  cotton,  this 
alone  sometimes  seems  to  afford  relief. 

When  a  joint  is  fixed  on  a  splint,  it  must  be  held  in  a 
position  which  is  comfortable  to  the  patient.  Simply  to  put 
a  posterior  splint  upon  a  leg  where  the  knee  is  affected  is 
often  to  give  extreme  pain  to  the  patient. 

If,  on  the  other  hand,  the  joint  be  fixed  in  the  position 
which  it  assumes  because  of  the  swelling  of  the  joint,  the 
patient  will  be  comfortable.  If  the  case  is  one  of  true  rheu- 
matic fever,  there  is  no  danger  of  the  joint  becoming  perma- 
nently fixed  in  an  abnormal  position,  because,  as  stated  in  the 
beginning  of  this  article,  the  arthritis  entirely  recovers  in  true 
rheumatism,  and,  indeed,  this  entire  recovery  of  an  arthritis 
is  a  mark  of  the  true  rheumatic  character  of  the  condition. 


RHEUMATIC   FEVER.  119 

When  the  patient  is  bathed  in  sweat,  this  annoying  symptom 
can  be  greatly  reHeved  by  carefully  sponging  the  body  with 
tepid  water,  and  then  sponging  off  lightly  with  alcohol.  This 
gives  a  great  deal  of  comfort  to  the  patient,  who  is  annoyed 
with  this  extremely  unpleasant  symptom. 

As  intimated  above,  the  portal  of  entry  in  this  condition 
is  frequently  the  tonsils.  The  tonsils  therefore  should  be  care- 
fully watched,  and  applications  of  an  ordinary  Dobell's  solution, 
boric  acid  solution  or  simple  normal  salt  solution,  should  be 
made,  preferably  in  the  form  of  sprays.  It  is  the  custom  of 
certain  physicians  to  recommend  that  inflamed,  infected  ton- 
sils should  be  removed  in  the  course  of  the  acute  infection  of 
rheumatism.  To  the  writer's  mind,  this  is  an  error.  He  has 
seen  so  many  serious  complications  result  from  the  removal 
of  the  tonsils  during  the  acute  infection,  that  he  feels  that  it 
is  a  dangerous  procedure.  However,  when  an  individual  has 
had  a  number  of  attacks  of  tonsillitis,  accompanied  by  rheu- 
matism, and  the  tonsils  remain  cryptic  during  the  intermis- 
sions, these  tonsils  certainly  should  be  removed. 

The  hyperpyrexia  and  the  cerebral  symptoms  which 
accompany  rheumatism,  are  best  treated  by  cold  sponges  or 
cold  baths,  and  in  cases  where  the  delirium  is  extremely 
severe,  by  blood-letting. 

The  pain,  which  is  extremely  severe  in  certain  instances, 
should  be  controlled  by  morphin,  when  it  is  severe  enough 
to  prevent  the  patient  from  resting;  rest,  as  said  before,  being 
the  essential  point  of  the  treatment.  Care,  however,  must  be 
taken,  when  morphin  is  given  under  these  conditions,  that 
the  administration  be  carefully  controlled,  in  order  that  the 
patient  be  not  allowed  to  develop  a  morphin  habit. 

Care  of  the  teeth  in  the  very  early  stages  of  rheumatism 
is  of  the  greatest  importance.  Sordes  about  the  teeth  and 
old  pyorrhea  will  often  keep  up  indefinitely  the  attack  of 
arthritis,  which  is  apparently  a  true  rheumatism.  In  such 
instances  cleansing  of  the  mouth  will  cause  a  cessation  of  the 
attack. 

Internal  Medication.  Some  compound  of  salicylic  acid  is 
used  the  world  over  in  every  case  of  acute  rheumatism.  It 
seems  to  the  author  that  the  administration  of  this  drug  is 
of  the  highest  importance.    In  the  first  place,  when  a  case  is 


120  SPECIFIC    INFECTIONS. 

proved  to  be  a  case  of  rheumatic  fever,  it  should  be  given 
one  of  the  salicylates  in  large  enough  and  frequent  enough 
doses  to  bring  about  the  therapeutic  symptoms  of  the  admin- 
istration of  that  drug.  Salicylate  of  soda  can  be  given  in  15- 
grain  (1  Gm.)  doses,  well  diluted,  every  three  hours,  until 
the  subject  complains  of  tinnitus  and  nausea,  or  of  one  of  the 
other  untoward  symptoms  of  the  administration  of  the  drug. 
When  it  brings  about  gastric  disturbance  it  may  be  com- 
bined with  bicarbonate  of  soda  in  equal  amounts.  This 
routine  should  be  kept  up  for*  four  or  five  or  six  days 
during  the  attack  of  the  rheumatism.  If,  in  the  course  of 
five  or  six  days,  or  perhaps  a  week,  no  good  results  have 
come  from  the  administration  of  the  salicylate  in  this  form, 
then  either  the  form  of  the  drug  should  be  changed  or  the 
salicylate  administration  should  be  stopped  entirely.  I  am 
quite  sure  that  I  have  seen  many  cases  of  deranged  digestion, 
depression,  and  weak  heart  from  a  very  prolonged  adminis- 
tration of  the  salicylates,  in  cases  where  they  were  doing  no 
good.  Other  forms  of  salicylates  may  be  used.  Acetyl 
salicylic  acid  (aspirin),  given  in  10-grain  (0.66  Gm.)  doses, 
every  three  hours,  is  often  more  beneficial  and  gives  more 
relief  than  does  the  salicylate  of  soda.  Phenol  salicylate  or 
salol  may  be  tried,  but  in  my  hands  it  has  not  been  nearly  so 
efBcacious  as  either  of  the  other  two. 

Salicylic  acid,  in  doses  of  10  grains  (0.66  Gm.),  given  in 
capsules  every  three  hours,  of  course  may  be  tried,  but  it 
always  seems  tliat  the  administration  of  the  acid  causes  more 
digestive  disturbance  than  does  the  use  of  one  of  its  salts. 
The  administration  of  alkalies  often  gives  relief;  these  may 
be  used  in  the  form  of  citrate  of  potassium,  15  grains  (1  Gm.) 
every  three  hours ;  or  as  bicarbonate  of  soda,  combined  with 
bromid  of  potassium,  10  grains  (0.66  Gm.),  every  three  hours. 
If  the  joints  do  not  very  rapidly  get  better,  if  after  all  acute 
symptoms  have  disappeared,  they  still  remain  swollen  and 
stiff,  very  light  massage  may  be  guardedly  practised.  Great 
care,  however,  must  be  taken  that  this  massage  does  not  give 
pain  to  the  patient.  While  in  suitably  selected  cases  this  pro- 
cedure may  be  of  great  value,  on  the  other  hand,  it  may  do 
the  greatest  amount  of  harm ;  and  I  am  sure  reinfection 
occurs   by   massaging  the  joints   too   early.     Therefore   it   is 


RHEUMATIC    FEVER.  121 

better  to  err  on  the  side  of  safety,  and  to  allow  a  joint  to  be 
untouched  if  it  gives  the  slightest  amount  of  pain  to  move  it. 
Certainly  indiscriminate  rubbing  by  members  of  the  family 
should  be  severely  frowned  upon. 

If  the  arthritides  resolve  slowly,  light  blisters  over  the 
joints,  the  blister  being  allowed  to  remain  one  or  two  hours, 
or  slight  applications  of  the  actual  cautery,  often  will  start  a 
resorption  of  the  exudative  material.  Baking  with  superheated 
air  is  of  value. 

It  has  been  stated  above  that  endocarditis  is  the  one 
complication  of  rheumatic  fever  which  is  of  the  great- 
est importance.  Therefore  daily  examination  of  the  heart  of 
rheumatic  subjects  should  be  made  throughout  the  entire 
course  of  the  disease,  and  the  slightest  appearance  of  any 
endocardial  trouble  should  be  a  sign  that  the  patient  must 
remain  quiet  until  all  fever,  leucocytosis,  and  local  signs  of 
cardiac  disease  have  disappeared,  except,  of  course,  the  mur- 
mur, which  tends  to  remain  permanently. 

The  question  as  to  when  the  patient  shall  get  out  of  bed 
is  always  one  of  great  importance.  Usually  as  soon  as  the 
acute  attack  has  disappeared,  the  patient  remains  still  slightly 
stiff,  with  a  small  amount  of  pain,  but  he  clamors  to  get  out 
of  bed.  He  should  be  kept  flat  on  his  back  until  absolutely 
all  of  the  acute  symptoms  have  disappeared,  particularly 
until  the  joints  can  be  freely  moved  without  pain,  and  until 
the  fever  and  the  leucocytosis  disappear  permanently.  Too 
early  rising  is  the  reason  for  prolonged  attacks  of  rheumatic 
fever  which  have  relapse  after  relapse. 

The  management  of  convalescence  is  important.  The 
patient  is  weak  and  anemic,  and  therefore  should  be  well 
clothed  and  kept  at  rest  in  the  open  air,  allowing  him  to  move 
about  only  a  small  amount  at  first,  and  gradually  increasing 
the  exercise  as  he  becomes  more  convalescent.  He  should  be 
given  an  abundance  of  good  food — meat,  milk  and  eggs — a 
mixed  general  diet.  The  old  habit  of  forbidding  cases  of 
acute  rheumatic  fever  from  the  use  of  meat  is  a  mistake. 

Medicines  for  the  convalescent  are  important.  Where  the 
joints  remain  stiff',  the  use  of  iodid  of  potassium,  5  grains 
(0.34  Gm.),  three  times  a  day,  is  perhaps  of  some  importance, 
but  if  the  administration  of  this  drug  causes  a  loss  of  appetite 


122  SPECIFIC   INFECTIONS. 

it  is  better  to  discontinue  its  use.  Iron  is  of  value ;  iron  in  the 
form  of  Blaud's  pills,  5  grains  (0.34  Gm.),  three  times  a  day, 
care  being  taken  that  the  pill  is  one  of  the  soft  variety, 
or  that  the  pill  mass  is  powdered  and  taken  in  capsules. 
Basham's  mixture  can  be  used  in  lieu  of  Blaud's  pills,  and  is 
an  efficacious  method  of  administering  the  iron.  Where  the 
anemia  is  very  severe,  hypodermic  injections  of  the  citrate  or 
lactate  of  iron  can  be  used,  instead  of  administering  this  metal 
by  the  mouth.  Some  authors  believe  this  is  the  only  proper 
way  to  administer  iron,  but  with  this  opinion  the  author  does 
not  agree,  as  he  has  seen  rapid  convalescence  and  rapid  blood 
reconstruction  occur  under  the  use  of  Blaud's  pills. 

The  Use  of  Vaccines.  So  far  as  the  author  is  aware  there 
is  no  well-founded  proof  that  the  use  of  rheumatic  vaccines 
is  of  the  least  value  in  the  treatment  of  acute  rheumatism. 
Certainly  the  use  of  stock  vaccines  is  not  justifiable.  If 
Poynton's  and  Payne's  views  (that  the  Micrococcus  rheu- 
maticiis  is  the  cause  of  the  disease)  be  well  founded,  then 
possibly  the  use  of  vaccines  of  this  bacterium  may  be  of  some 
value,  but  thus  far  it  has  not  been  proved  to  be  of  any  use. 
There  is  no  serum  which  is  of  value.  The  administration  of 
the  various  remedies  on  the  market,  in  the  form  of  rheumatic 
serums,  phylacogens  and  rheumatic  vaccines,  is  not  to  be 
advised.  On  the  other  hand,  it  has  been  lately  shown  that 
the  intravenous  injection  of  almost  any  foreign  proteid,  in 
certain  cases  of  arthritis,  whether  they  are  rheumatic  or  not, 
is  followed  by  symptomatic  cure. 

It  seems,  however,  to  the  writer  that  this  method  of  treat- 
ing arthritis  is  not  to  be  undertaken  without  care.  One  may 
surely  remove  the  pain  and  swelling  of  certain  cases  of 
arthritis  by  the  administration  of  ^  minim  of  Colle's  fluid, 
or  of  foreign  protein  of  some  other  form,  such  as  typhoid  vac- 
cine, but  the  question  still  remains  whether  one  is  not  simply 
treating  a  symptom  instead  of  removing  the  cause.  The 
symptom  surely  should  be  treated,  but  the  case  should  not  be 
dismissed  with  their  disappearance  as  the  only  evidence  of 
cure.  The  use  of  foreign  proteins  in  this  way  also  occasion- 
ally brings  about  such  severe  reactions  that  the  patient's  life 
may  be  jeopardized, 


ACUTE   TONSILLITIS.  123 

ACUTE   TONSILLITIS. 

Acute  tonsillitis  is  an  inflammation  of  the  tonsils,  charac- 
terized by  redness  of  the  tonsils,  and,  indeed,  of  the  whole 
pharynx,  and  by  an  exudate  upon  the  tonsils,  frequently 
occupying"  the  follicles  alone,  sometimes  spreading  over  the 
entire  tonsil  in  a  pultaceous  mass. 

The  general  symptoms  are  a  chilly  sensation,  aching  of 
the  limbs,  headache,  resembling  in  every  way  infectious  colds, 
but  with  the  added  inflammation  of  the  tonsils,  as  stated 
above. 

The  micro-organisms,  which  are  usually  found  in  this 
infection,  belong  to  either  the  streptococcus  or  staphylococcus 
group,  the  more  severe  forms,  however,  being  a  true  strepto- 
coccic sore  throat.  Rarely  are  these  bacteria  found  in  pure 
culture  but  pneumococci,  micrococci  catarrhalis,  and  many 
other  forms  of  bacteria  are  found. 

The  disease  is  highly  transmissible,  and  every  case  of  ton- 
sillitis should  be  isolated,  where  it  is  at  all  practicable.  The 
danger  in  this  particular  disease  is  the  possible  mistaking 
diphtheria  for  this  infectious  form  of  sore  throat.  What  has 
been  said  in  regard  to  cultures  of  the  throat  in  diphtheria 
should  be  carried  out  in  every  case  of  exudative  sore  throat, 
and,  when  there  is  any  grave  reason  for  doubt  that  the  case 
is  one  of  diphtheria,  a  protective  dose  of  diphtheria  antitoxin 
should  be  given.  Another  danger  of  follicular  tonsillitis  is 
that  the  tonsils  thus  become  a  portal  of  entry  for  other 
organisms,  and  eventually  arthritis,  endocarditis,  and  other 
serious  conditions  arise  as  secondary  deposits  of  the  infecting 
organism. 

TREATMENT. 

Every  case  of  follicular  tonsillitis  should  be  put  to  bed,  and 
kept  in  bed  until  it  is  entirely  well.  Local  treatment  is  often 
of  great  value.  The  use  of  ice  held  in  the  mouth,  or  of  an 
ice  poultice,  often  gives  considerable  relief.  Sprat's  of  a  mild 
antiseptic  solution,  such  as  suggested  for  infectious  colds,  that 
is  Dobell's  solution,  or  normal  salt  solution,  are  of  the  great- 
est value.  The  application  of  a  5  per  cent,  solution  of  nitrate 
of  silver,  of  tannic  acid  in  glycerin,  20  grains  (L3  Gms.)  to 


124  SPECIFIC    INFECTIONS. 

the  ounce  (30  mils),  and  of  bicarbonate  of  soda  spread  over 
the  tonsil  also  is  advised.  A  mixture  of  tincture  of  chlorid 
of  iron  and  of  bichlorid  of  mercury  in  lemon-juice  and  syrup, 
is,  in  the  writer's  practice,  of  more  actual  curative  value  than 
any  other  medication.  The  tincture  of  chlorid  of  iron  may 
be  used  in  10-drop  (0.62  mil)  doses,  and  the  bichlorid  of  mer- 
cury in  from  ^04  to  %o  of  3-  ^rain  (0.002  to  0.001  Gm.)  every 
three  hours.    The  prescription  may  be  written  as  follows : 

B  Hydrargyri  chloridi  corrosivi   gr.  M  (0.048  Cm.). 

Tincturje  ferri  chloridi, 

Succi  limoni    aa  f oss  ( 15  mils) . 

Syrupi    q.   s.  fBiij   (90  mils). 

M.    S. :  Teaspoonful  (4  mils)  every  3  hours. 

The  salicylates,  sodium  salicylate,  in  15-g'rain  (0.97  Gm.) 
doses  every  three  hours,  phenol  salicylate  (salol)  every  three 
hours  in  from  5-  to  10-  grain  (0.32  to  0.65  Gm.)  doses,  acid- 
acetyl-salicylic  (aspirin)  in  5-grain  (0.32  Gm.)  doses  are  of 
value,  but  are  of  less  value  than  the  iron  mixture  given  above. 

After  the  attack  of  tonsillitis,  the  individual  is  apt  to  be 
very  weak,  and  should  avoid  overexertion.  During  the  attack 
and  after  it,  the  heart  should  be  very  carefully  examined, 
because,  as  said  previously,  endocarditis  is  one  of  the  sequels 
of  these  attacks  of  tonsillitis,  and  the  early  treatment  of  endo- 
carditis is  the  only  treatment  which  is  of  actual  curative  value. 

FEBRICULA  (Ephemeral  Fever). 

This  title  is  g-iven  by  Osier  to  a  set  of  symptoms  charac- 
terized by  fever,  without  any  other  diagnostic  symptoms. 
There  are  unquestionably  many  cases  where  there  is  fever,  in 
which  we  are  unable  to  find  the  cause  of  infection.  It  seems 
to  the  writer,  however,  that  perhaps  the  name  of  infection  of 
unknown  cause  would  be  better  than  to  give  the  name  febri- 
cula  or  ephemeral  fever  to  this  class  of  cases.  The  reason  for 
this  is  that  we  are  satisfied  with  the  name  febricula,  and  it 
may  tempt  us  to  cease  our  efforts  to  find  the  cause  for  the 
outbreak. 

TREATMENT. 

The  rule  to  follow  in  these  cases  of  unknown  infection,  in 
order  to  be  on  the  safe  side,  is  to  consider  the  case  as  some 


INFECTIOUS   JAUNDICE.  125 

definitely  known  infectious  disease,  such  as  typhoid  fever, 
measles,  scarlet  fever,  etc.,  the  one  it  most  closely  resembles, 
until  the  opposite  is  proven  to  be  the  fact.  In  this  way  we 
will  avoid  treating  cases  under  the  name  of  febricula  which  are 
really  abortive  cases  of  any  of  these  infectious  diseases.  The 
treatment  necessarily  is  entirely  symptomatic.  Rest  in  bed, 
cooling-  drinks,  freedom  from  excitement  and  exposure  are  all 
that  can  be  done  until  an  actual  diagnosis  is  made. 

INFECTIOUS    JAUNDICE    (Weil's  Disease). 

This  condition  is  characterized  in  some  cases  by  gradual 
onset,  and  in  other  cases  by  sudden  onset,  of  developing 
jaundice,  enlargement  of  the  liver  and  splenomegaly.  Some- 
times there  are  decided  nervous  symptoms,  delirium  being 
very  common.     There  is  marked  pain  in  the  abdomen. 

In  the  tropics  the  disease  may  be  mistaken  for  mild  cases 
of  yellow  fever  or  of  dengue.  It  may  also  be  mistaken  for 
simple  catarrhal  jaundice,  or  for  one  of  the  more  grave  cases 
of  infectious  jaundice,  or  for  acute  yellow  atrophy  of  the  liver. 
All  these  conditions  must  be  taken  into  consideration  in 
every  febrile  attack  characterized  by  abdominal  pain  and  by 
jaundice.     The  specific  organism,  if  one  exists,  is  not  known. 

TREATMENT. 

The  treatment  is  entirely  symptomatic.  Rest  in  bed  is 
essential,  and,  if  the  temperature  is  high,  hydrotherapy  should 
be  practised.  If  abdominal  pain  is  severe,  hot  fomentations 
are  useful.  If  the  toxemia  is  great,  large  amounts  of  water, 
very  mild  laxatives,  and  often  the  intravenous  and  subcutane- 
ous use  of  salt  solution  is  of  great  value.  Severe  purgation 
is  contraindicated,  because  there  is  always  more  or  less  inflam- 
mation of  the  gastro-intestinal  mucous  membranes,  and  these 
purgatives  certainly  irritate,  and  increase  this  inflammation. 

There  is  a  great  deal  of  prostration  following  these  cases, 
and  the  convalescence  is  often  prolonged.  Here  the  individual 
should  take  care  not  to  return  to  his  ordinary  vocation  for  a 
considerable  time  after  the  attack.  He  should  rest  in  the  open 
air,  take  large  amounts  of  digestible  food,  sucli  as  milk,  eggs 
and  cereals,  and  as  much  meat  as  he  can  possibly  digest  with 
comfort. 


126  SPECIFIC    INFECTIONS. 

GLANDULAR   FEVER. 

This  disease  was  first  described  as  an  entity  in  1889 
by  Pfeiffer.  It  occurs  usually  in  young  children.  The  patient 
complains  first  of  sore  throat  with  some  redness  of  the  fauces, 
then  the  superficial  glands  become  involved,  particularly  those 
of  the  post  cervical  region.  The  temperature  rises  to  101°  to 
103°  F.  (38.3°  to  39.4°  C.)  ;  the  enlarged  glands  vary  in  size, 
often  being  as  large  as  an  egg.  The  disease  is  unquestion- 
ably of  an  infectious  character,  and  occurs  commonly  between 
October  and  June.  The  glands  are  tender  to  the  touch,  and 
the  liver  and  spleen  are  frequently  enlarged.  Where  prac- 
ticable, the  children  should  be  isolated,  kept  strictly  in  bed, 
and,  on  account  of  the  danger  of  inflammation  of  the  kidneys, 
the  diet  should  be  light.     Sprays  to  the  throat  should  be  used. 

West,  in  an  epidemic  of  96  cases,  has  found  small  doses 
of  calomel  to  be  the  best  drug  to  use. 

The  patients  are  extremely  weak,  and  require  tonics,  fresh 
air,  and  good  food  as  after  treatment. 

ACTINOMYCOSIS. 

Actinomycosis,  a  disease  rather  common  in  cattle,  is  some- 
times communicated  to  man. 

The  writer's  knowledge  of  actinomycosis  and  glanders  is 
very  limited,  and  derived  largely  from  the  literature. 

The  parasite  to  which  the  disease  is  due  is  the  Streptothrix 
actinomyces,  and  can  be  found  in  the  discharges  from  the 
lesions  of  the  disease.  If  it  affects  the  lungs,  actinomyces  may 
be  found  in  the  sputum.  The  digestive  tract  has  been  affected. 
The  actinomyces  have  been  found  in  the  cavities  of  the  teeth. 
Frequently  the  jaw  is  affected.  Enlargement  of  the  jaw  on 
one  side  may  occur,  which  looks  extremely  like  sarcoma,  the 
diagnosis  being  made  only  by  the  discovery  of  the  actino- 
myces. The  tongue  has  been  infected,  small  nodules  occur- 
ring over  various  parts  of  the  tongue.  Actinomyces  have  been 
found  in  the  cecum,  and  in  the  appendix,  the  intestinal  form 
being  usually  regarded  as  appendicitis.  Of  course  there  is  no 
possibility  of  a  diagnosis  of  the  nature  of  the  appendicitis, 
unless  there  be  some  superficial  lesion. 


HELMINTHIASIS.  127 

Pulmonary  actinomycosis  is  characterized  by  cough,  fever, 
wasting,  and  mucopurulent  expectoration.  The  lesions  are 
usually  widespread  or  there  may  be  simply  a  chronic  bron- 
chitis, and  here,  as  stated  above,  the  diagnosis  is  made  by 
discovering  the  actinomyces  in  the  sputum. 

Miliary  actinomycosis  is  a  variety  in  which  the  lesions  are 
scattered  nodules  throughout  the  lungs,  and  unless  there  be 
some  superficial  lesion  the  diagnosis  is  not  possible  before 
death. 

There  are  other  cases  in  which  the  disease  is  more  destruc- 
tive, and  affects  larger  portions  of  the  lung.  The  writer  once 
saw  a  case  which  simulated  closely  a  pleural  effusion.  The 
chest  was  tapped ;  a  small  amount  of  liquid  was  obtained ;  the 
lung  was  then  explored,  and  the  material  resembling  the  sar- 
coma of  a  pleura  was  recovered,  which  disclosed  the  presence 
of  actinomyces. 

Cerebral  actinomycosis  is  described  in  isolated  cases,  the 
diagnosis  here  depending  entirely  upon  the  recovery  of  the 
actinomyces  from  the  parts.  As  Osier  says,  the  disease  is  in 
reality  a  chronic  pyemia.  Secondary  foci  may  occur  both  in 
pyemia  and  in  actinomycosis.  The  tendency,  however,  is 
rather  to  the  production  of  a  local  purulent  infection  which 
erodes  the  tissues,  and  is  very  destructive. 

TREATMENT. 

When  the  disease  is  local,  the  focus  should  be  entirely  re- 
moved, and  the  cavity  painted  with  iodin.  In  the  generalized 
infection,  the  use  of  iodid  of  potassium  large  doses,  40  to  60 
grains  (2^^  to  4  Gm.)  has  sometimes  proved  curative.  .Y-rays 
have  been  used  about  the  superficial  lesions  with  beneficial 
results.  Certainly,  however,  if  a  local  lesion  exists,  it  had  bet- 
ter be  excised,  curetted,  painted  with  iodin,  after  which  the 
use  of  the  .a--ray  may  be  tried  in  order  to  kill  any  germs  linger- 
ing in  the  adjacent  tissues. 

HELMINTHIASIS. 

The  diseases  due  to  helminths  or  worms  vary  with  the 
type  and  location  of  the  parasite  infesting  the  individual. 


128  SPECIFIC    INFECTIONS. 

These  parasites  may  be  divided  into  those  whose  habitat  is 
the  intestinal  canal,  and  those  infesting  other  portions  of  the 
body.  Of  the  intestinal  parasites  the  most  common  are  the 
flukes,  or  trematodes;  the  cestodes,  or  tapeworms;  and  the 
nematodes,  or  round  worms. 

The  first  of  these,  the  flukes,  or  trematodes,  have  flattened 
leaf-shaped  bodies.  Infestation  by  them  gives  rise  to  so-called 
distomiasis.  In  these  conditions  particularly  the  symptoms 
depend  upon  the  site  of  the  lodgment  of  the  trematodes. 
These  forms  are  recognized : — 

1.  Pulmonary  distomiasis. 

2.  Hepatic  distomiasis. 

3.  Intestinal  distomiasis. 

4.  Haemic  distomiasis — bilharziasis. 

5.  Schistosma  Japonica  oel  Cattoi. 

PULMONARY    DISTOMIASIS. 

This  is  due  to  infection  by  Paragonimus  ivcstermanii.  The 
symptoms  are  chronic  cough,  yellow  or  red  sputum,  and  the 
presence  of  enormous  numbers  of  the  ova  in  the  sputum.  It 
is  constantly  mistaken  for  tuberculosis,  and  can  be  differen- 
itated  only  from  this  condition  by  the  examination  of  the 
sputum.  It  is  common  in  Japan  and  China.  According  to 
those  familiar  with  the  disease,  there  is  no  specific  treatment. 
General  measures,  disinfection  of  the  sputum,  removal  from 
the  region  in  which  they  become  infected,  are  depended  upon 
to  relieve  the  sufiferers. 

HEPATIC    DISTOMIASIS. 

There  are  a  number  of  flukes  (Distoma)  found  in  the  liver 
of  the  different  individuals  who  are  infested.  According  to 
Osier,  "Six  species  of  liver  flukes  are  known  to  occur  in  man. 
More  specifically  these  are:  (1)  the  common  liver  fluke  {Fas- 
ciola  hepatica),  which  is  a  very  common  parasite  in  the  rumi- 
nants. It  is  a  rare  and  accidental  parasite  in  man,  but  in  Syria 
a  strange  disease  called  'Halzoun'  is  caused  by  eating  raw  goat 
liver  infected  with  the  parasite.  (2)  The  Lancet  fluke  (Dicro- 
coelium    [Distoma]    lanceatum).      (3)    Opisthorchis    (Distoma) 


DISTOMIASIS.  129 

felineus,  which  is  found  in  Prussia  and  Siberia,  and  by  Ward 
in  cats  in  Nebraska.  (4)  Opistliorchis  novcrca  (Distomum  con- 
junctum),  the  Indian  liver  fluke  described  in  man  by  McCon- 
nell.  (5)  Opistliorchis  (Distoma)  sinensis,  which  is  by  far  the 
most  important  of  the  liver  flukes,  and  occurs  extensively  in 
Japan,  China,  and  India.  It  is  10  to  20  mm.  long  by  2  to  5 
mm.  broad.  The  eggs  are  oval,  27  ^  to  30^^  by  15  ^^  to  17^^ 
dark  brown  with  sharply  defined  operculum.  A  number  of 
imported  cases  have  been  found  in  Canada  and  in  the  United 
States.    White  found  18  cases  in  San  Francisco." 

The  liver  is  enlarged,  cirrhosis  occurs,  diarrhea  develops, 
at  first  appearing  in  attacks,  and  later  being  almost  continuous. 
Occasionally  jaundice  appears.  The  diagnosis  can  be  made 
easily,  and  only,  by  discovery  of  the  ova  in  the  stools. 

The  same  unsatisfactory  treatment  must  be  used — removal 
from  the  infected  area,  and  sustaining  the  patient  with  general 
measures.  Laparotomy  has  been  suggested  in  order  to  reach 
the  bile  ducts  and  remove  the  parasites  from  the  ducts. 

In  the  infected  areas  the  species  of  fluke  infecting  the  in- 
dividual should  be  known,  and  then  the  source  of  infection 
destroyed — infected  cats  and  dogs,  and  avoidance  of  eating  raw 
liver,  when  sheep,  cattle  and  goats  are  the  hosts  of  the  fluke. 

INTESTINAL    DISTOMIASIS. 

According  to  Stiles,  several  species  of  flukes  are  respon- 
sible for  this  condition.  The  stools  should  be  examined.  The 
symptoms  of  some  are  nil,  in  others  there  are  diarrhea  and 
bloody  stools. 

Thymol  and  calomel  are  used  to  rid  the  intestines  of  the 
parasite. 

HEMIC    DISTOMIASIS;    BILHARZIASIS. 

This  infection  is  due,  according-  to  Stiles,  to  two  or  possibly 
three  species  of  flukes,  the  Asiatic  and  African  blood-fluke. 
In  Egypt,  epidemic  hematuria  has  been  known  for  a  long 
while,  and  is  one  of  the  most  important  of  parasitic  diseases. 
It  is  due  to  infection  l:)y  the  African  blood-fluke,  described  by 
Bilharz  in  1851  or  1852. 

9 


130  SPECIFIC   INFECTIONS. 

According  to  Stiles,  the  complete  life  history  of  the  para- 
site is  unknown,  but  evidence  is  accumulating  which  indicates 
that  the  parasites  gain  access  to  the  human  body  through  the 
skin,  though  the  embryos  may  be  taken  into  the  intestinal 
canal  through  impure  water.  The  ova  and  parasites  are  found 
in  various  parts  of  the  body,  causing  irritation,  fibroid  changes 
and  papillomata  of  the  rectum  and  bladder. 

The  symptoms  vary  with  the  intensity  of  the  infestation, 
and  with  the  particular  parts  most  involved.  When  the  seat 
of  the  most  severe  infestation  is  greatest  in  the  genito-urinary 
system,  "irritability  of  the  bladder,  dull  pain  in  the  perineum, 
and  hematuria  are  the  commonest  symptoms." 

Should  the  rectum  be  involved,  the  most  prominent  symp- 
toms are  "bloody  stools,  diarrhea,  prolapse  of  the  rectum,  and 
papilliform  growths."  In  common  with  many  other  parasitic 
affections,  there  may  be  severe  infestation  without  any  definite 
symptoms. 

The  treatment  is  highly  unsatisfactory.  No  remedy  is 
known  which  will  destroy  the  ova  in  the  blood.  Operative 
measures  upon  the  bladder  and  rectum  are  sometimes  per- 
formed for  the  local  condition.  If  perineal  fistulae  occur  they 
are  treated  surgically,  as  is  prolapse  of  the  rectum. 

Male  fern,  santonin,,  quinin  and  methylene  blue  have  all 
been  recommended;  quinin  and  methylene  blue  with  the  hope 
of  affecting  the  ova  or  embryos  in  the  blood ;  santonin  and 
male  fern,  of  course,  only  for  the  purpose  of  ridding  the  in- 
testine of  the  parasite. 

DISEASES  CAUSED  BY  CESTODES. 

Tapeworm  infection  is  characterized  by  the  presence  of 
the  adult  worm  in  the  intestine,  and  the  larvze  of  the  tapeworm 
in  various  other  organs.  The  tapeworms  which  give  rise  to 
symptoms  and  which  are  of  importance  in  clinical  medicine  in 
this  country  are : 

1.  TcEfiia  solium,  or  pork  tapeworm. 

2.  Tccnia  saginata,  or  beef  tapeworm. 

3.  Dibothriocephahis  latus  or  fish  tapeworm. 

The  symptoms  of  these  three  infestations  may  be  taken  up 
together.     First,  the  presence  of  any  of  the  tapeworms  may 


DISEASES    CAUSED    BY    CESTODES.  131 

give  rise  to  absolutely  no  symptoms.  All  these  varieties  of 
tapeworms  appear  very  largely  in  the  United  States,  indeed, 
around  the  entire  world.  Dihothriocephalns  latus  (fish  tape- 
worm), however,  is  common  along-  the  Baltic  Sea,  in  parts  of 
Switzerland,  and  in  Japan.  The  beef  tapeworm  is  due  to  eat- 
ing uncooked  beef  which  contains  the  larvze  of  the  worm,  and 
Tcrnia  solium  is  due  to  eating  uncooked  pork,  which  contains 
the  ova  of  the  pork  tapeworm.  The  Dihothriocephalns  latus  in- 
vades the  human  intestine  probably  from  the  eating  of  un- 
cooked or  undercooked  fish,  bearing  the  larvae  of  this  worm. 
The  heads  of  both  the  beef  tapeworm  and  the  pork  tapeworm 
are  extremely  small,  being  a  black  object  about  the  size  of  a 
pin  head.  The  pork  tapeworm  head  is  round  and  has  four 
sucking-disks,  and  two  rows  of  booklets  around  it.  By  the 
means  of  these  sucking-disks  and  the  booklets,  the  parasite 
gets  its  hold  on  the  mucous  membrane  of  the  intestine.  The 
length  of  a  mature  tapeworm  is  from  six  to  twelve  feet. 

The  head  of  the  beef  tapeworm  is  rather  square,  has  four 
sucking-disks,  and  has  no  row  of  booklets  around  it.  It  is  by 
means  of  these  sucking-disks  that  the  head  makes  fast  to  the 
mucous  membrane  of  the  intestine.  The  length  of  this  tape- 
worm is  from  fifteen  to  twenty  feet,  or  more. 

The  head  of  the  fish  tapeworm  is  dift'erent  from  the  other 
tapeworms,  is  long  and  narrow,  and  has  a  slit  on  one  side  by 
which  it  holds  fast  to  the  mucous  membrane.  This  worm 
measures  from  twenty-five  to  thirty  feet  when  matured,  and 
the  segments  of  this  tapeworm  are  wide  and  short,  entirely 
different  from  the  shape  of  the  segments  of  the  other  tape- 
worms. The  method  of  infestation  is  practically  the  same  in 
all  forms  of  tapeworms.  The  adult  segments  are  extruded 
from  the  bowel  of  the  host,  are  then  swallowed  by  the  hog, 
fish,  or  cattle,  as  the  case  may  be.  The  ova  hatch  in  the  intes- 
tines of  these  animals,  the  larvae  penetrate  into  the  muscles. 
live  there,  and  become  quiescent.  The  flesh  of  these  animals 
is  swallowed  in  an  uncooked  state  by  man ;  the  embryo  de- 
velops in  the  intestine ;  and  the  infestation  of  man  is  complete. 

Sometimes  there  are  vague  nervous  symptoms  arising  from 
the  tapeworm,  or  there  may  be  actual  convulsions.  The  ordi- 
nary symptoms  attributed  to  tapeworms  such  as  increased 
appetite,    jerky   muscle    symptoms    and    so    on,    are    perhaps 


132  SPECIFIC   INFECTIONS. 

rather  imaginary  on  the  part  of  the  patient;  indeed,  they  are 
simple  signs  of  indigestion,  without  an)^  particular  reference  to 
the  worrn  which  may  be  present.  Occasionally  links  of  the 
tapeworm  are  found  in  the  vermiform  appendix;  the  writer 
has  notes  of  one  patient  who  was  operated  on  for  repeated 
attacks  resembling  appendicitis  and  at  the  operation  four  links 
of  tapeworm  were  found  in  the  vermiform  appendix.  This 
particular  case  I  am  quite  certain  could  not  have  been  diag- 
nosed anything  other  than  appendicitis,  yet  the  appendix  itself 
at  the  operation  was  found  to  be  relatively  normal. 

The  blood  of  the  host  in  infestation  by  the  fish  tapeworm, 
or  Dihothriocephaliis  latus,  shows  a  very  extreme  anemia,  and 
resembles  the  blood-picture  of  pernicious  anemia  from  which 
it  can  be  differentiated  only  by  finding  the  worm  in  the  feces. 
There  is  usually,  as  is  common  with  intestinal  parasites  of 
any  kind,  more  or  less  eosinophilia  in  these  cases. 

The  diagnosis  is  perfectly  easy,  and  consists  of  finding 
either  the  ova  or  the  links  of  the  tapeworm  in  the  feces.  It  is 
a  great  mistake  to  treat  a  person  for  tapeworm,  or  indeed  for 
any  other  kind  of  intestinal  worms,  without  being  sure  of  the 
diagnosis.  The  examination  of  the  feces  should  be  made  in 
every  suspected  case,  and  unless  the  ova  or  the  links  or  the 
adult  worm  is  found  in  the  feces,  no  treatment  should  be  given. 
As  said  in  the  beginning,  the  symptoms  are  extremely  irregu- 
lar from  any  kind  of  an  intestinal  parasite,  and  treatment  can- 
not be  safely  based  upon  them. 

Prophylaxis  of  tapeworm  disease  is  most  important.  The 
first  step  should  be  the  careful  destruction  of  the  feces  con- 
taining the  ova  and  the  tapeworm.  This  can  easily  be  done 
either  by  burning  the  feces  or  by  mixing  them  with  some  solu- 
tion such  as  chlorinated  lime  or  strong  solution  of  bichloride 
of  mercury.  The  most  important  means  of  prevention  is  care- 
ful examination  of  the  butcher's  meat  in  the  abattoir.  In  this 
meat  fresh  ova  can  be  found  if  carefully  looked  for,  and  most 
Governments  now  have  a  regulation  in  which  all  meat  is  in- 
spected, both  beef  and  pork.  According  to  Stiles,  in  inspec- 
tion of  meat  special  stress  is  laid  upon  the  examination  of  the 
tongue  and  of  the  diaphragm,  which  are  favorite  seats  for  de- 
posit of  larvae  in  the  animals. 


DISEASES    CAUSED    BY    CESTODES.  133 

TREATMENT. 

Perhaps  as  important  a  part  of  the  treatment  of  tapeworm 
disease  is  preparation  of  the  patient  before  any  drug  is  given  ; 
indeed,  the  remedy  is  useless  without  this  preparation. 

At  the  beginning  of  the  treatment,  the  patient  should  be 
given  a  brisk  purge,  preferably  sulphate  of  magnesia  or  sul- 
phate of  soda.  F"ollowing  this  purge  the  patient  should  be 
absolutely  starved  for  24  hours,  nothing  except  water  being 
taken  into  the  stomach.  At  the  end  of  24  hours  he  should  be 
given  another  purge,  and,  after  this  has  acted,  the  selected 
vermifuge  is  to  be  g"iven.  Many  drugs  have  been  used  for  the 
cure  of  tapeworm.  The  one  which  has  been  most  useful  to 
the  writer  is  aspidium,  the  oleoresin  of  male  fern.  This 
should  be  given  in  doses  of  1  dram  (4. mils),  to  be  repeated  in 
2  hours.  It  is  perhaps  best  administered  in  capsules,  the 
wisest  way  to  prescribe  it  being  to  give  a  prescription  for  the 
oleoresin  and  at  the  same  time  a  prescription  for  empty  cap- 
sules. The  patient  can  fill  these  capsules  himself,  and  take- 
them.  If  they  are  bought  in  capsules  in  the  drug  store,  the 
capsules  are  very  apt  to  be  soiled  with  the  nauseating  taste  of 
the  drug.  Capsules  containing  the  oleoresin  of  the  male  fern 
are  manufactured,  but  are  no  more  effective,  and  are  more 
expensive  than  when  prepared  by  the  patient.  Another 
method  of  administration  is  the  fluid  extract,  a  dram  bemg 
mixed  in  sugar  and  then  swallowed.  This  is  not  a  very 
nauseating  way  of  taking  the  drug.  It  is  always  best  for  the 
patient  to  remain  quiet  after  taking  the  remedy,  in  order  to 
avoid  the  nausea  attendant  upon  its  use.  Two  hours  after  the 
last  dose  of  male  fern  has  been  administered,  the  patient  takes 
another  brisk  purge  of  magnesia  sulphate  or  sulphate  of  soda. 
This  last  stool  should  be  received  in  a  receptacle  containing" 
water,  for  the  reason  that  a  careful  search  must  be  made  for 
the  head,  and  the  head  is  so  small  that  it  may  be  very  readily 
overlooked  in  an  ordinary  stool. 

Pelletierin,  the  active  principle  of  pomegranate  seed,  is  a 
very  efficient  remedy  used  for  the  tapeworm.  This  can  be 
given  in  capsules,  in  doses  of  5  to  10  grains  (0.3  to  0.6  Gm.), 
repeated  every  two  hours  until  three  doses  are  taken.  This 
also  should  be  preceded  l^y  fasting  and  followed  by  a  purge, 


134  SPECIFIC   INFECTIONS. 

just  exactly  as  is  the  male  fern.  Pumpkin  seed  is  anoth«T 
remedy  which  has  been  used,  and  is  particularly  useful  where 
the  individual  is  old  and  weak.  Two  ounces  (62.2  Gms.)  of  this 
may  be  made  into  an  electuary  by  grinding  up  with  sugar.  It  is 
not  an  unpleasant  drug,  and  is  quite  effective.  Perhaps  the  great 
reason  of  failure  in  treating  tapeworm  is  failure  to  starve  the 
patient  a  sufficiently  long  time,  and  to  get  his  bowel  entirely 
empty  before  the  remedy  is  given.  Unless  the  head  is  brought 
away  the  patient  is  not  cured,  and  therefore  careful  search 
should  be  made.  However,  if  the  head  is  not  brought  away, 
it  is  no  positive  evidence  that  it  has  not  been  passed,  and  there- 
fore active  treatment  should  be  discontinued,  to  be  renewed  on 
appearance  of  the  links  in  the  bowels. 

SOMATIC    T^NIASIS. 

This  disease  is  due  to  the  infestation  of  the  human  being 
with  the  larvae  of  one  of  the  tapeworms.  The  two  most  com- 
mon tapeworms  which  give  rise  to  cysticeria  are  the  Tcenia 
solium  and  the  Tcenia  echinococcus. 

Cysticercus  cellulose  is  the  name  given  to  the  infestation  of 
the  human  being  by  the  larvae  of  the  tcBnia  solium. 

The  larvse  of  Tcenia  saginata,  or  beef  tapeworm,  may  infest 
man,  but  it  does  so  very  much  more  rarely  than  does  that  of 
Tcenia  solium.  The  symptoms  of  this  disease  depends  entirely 
upon  the  organs  infested  by  the  larvse.  A  general  infestation 
has  been  described,  in  which  the  symptoms  are  miscalled  those 
of  "rheumatism" ;  the  individual  is  sore,  is  stiff,  aches  all  over 
and  has  fever,  but  on  careful  examination  it  is  discovered  that 
this  so-called  "rheumatism"  is  not  an  actual  arthritis,  but  is 
due  to  soreness  in  the  muscles ;  still  more  careful  examination 
will  show  that  there  are  small  bodies  under  the  skin,  and  if 
these  are  taken  out,  they  will  be  found  to  be  the  larvse  of  the 
tapeworm. 

Nervous  symptoms  are  due  to  the  implantation  of  the  larvse 
in  the  spinal  axis.  Here  the  symptoms  depend  altogether 
upon  the  part  of  the  brain  or  cord  in  which  the  larvse  are 
situated.  There\  are  cases  on  record  in  which  large  numbers 
have  been  found  in  the  ventricles  of  the  brain  without  giving 
rise  to  any  symptoms  whatever.    Osier  reports  a  case  he  saw 


DISEASES    CAUSED    BY    CESTODES.  135 

in  which  there  were  symptoms  of  diabetes  and  vague  nervous 
symptoms.  Cases  with  paralysis  have  been  reported,  where 
the  cysticercus  has  been  located  in  one  of  the  active  centers, 
the  leg"  center,  etc.  The  larvae  have  been  found  and  demon- 
strated by  the  ophthalmoscope  during  the  life  of  the  patient  in 
the  vitreous  humor,  giving  rise  to  blindness  and  other  de- 
rangements of  sight. 

ECHINOCOCCUS    DISEASE. 

This  disease  is  due  to  the  infestation  of  the  human  being 
by  the  larvae  of  the  Tccnia  echinococcus.  This  tapeworm  is  not  a 
habitat  of  the  intestine  of  man,  but  is  found  in  the  intestine 
of  the  dog.  These  are  tiny  tapeworms,  not  more  than  three  or 
four  millimeters  in  length.  The  hog  and  the  ox  are  the  inter- 
mediary host  of  this  small  tapeworm.  The  segments  and  ova 
of  the  worm  are  taken  into  the  intestines  of  these  animals,  de- 
velop there,  and  find  their  way  into  the  solid  organs  where 
they  lodge.  There  is  irritation  and  inflammation  in  the  region 
in  which  these  larvae  come  to  rest,  and  this  finally  gives  rise  to 
a  cyst;  after  the  cyst  has  arrived  at  a  certain  size,  other 
"daughter  cysts"  develop  on  their  walls ;  when  these  daughter 
cysts  develop  sufficiently,  they  also  develop  cysts  on  their 
walls.     These  are  the  granddaughter  cysts. 

Such  cysts  are  filled  with  a  colorless  material.  On  the 
walls  little  granulations  occur  which  are  really  the  heads  of 
the  undeveloped  tapeworms.  These  heads  or  scolices^  present 
four  sucking-disks  and  a  row  of  booklets.  The  scolices,  taken 
into  the  intestine  of  the  dog,  are  capable  of  developing  an 
adult  tapeworm.  When  these  larvae  gain  access  to  man  they 
may  lodge  in  any  portion  of  the  human  economy.  The 
echinococcus  of  the  liver,  the  echinococcus  of  the  kidney,  the 
echinococcus  of  the  nervous  system  are  well  known  forms,  and 
give  rise  to  tumors  in  these  positions,  which  develop  pressure 
symptoms  depending  for  degree  upon  the  organ  interfered 
with. 

TREATMENT. 

The  treatment  of  echinococcus  disease  in  man  is,  unfor- 
tunately, unsuccessful,  except  from  the  surgical  standpoint. 
When  a  large  cyst  of  the  liver  exists,  it  may  be  excised.    If  the 


136  SPECIFIC    INFECTIONS. 

kidney  is  found  to  be  the  seat  of  an  echinococcus  cyst,  either  the 
cyst  or  the  whole  kidney  may  be  removed,  and  the  patient  be  per- 
fectly well  afterward.  Upon  the  position  of  the  cyst  in  the 
nervous  system  will  depend  the  availability  of  surgical  means 
of  relief. 

DISEASES  CAUSED  BY  NEMATODES. 

(ROUND  WORMS). 

The  most  important  round  worms  which  infest  man  are : 

1.  Ascaris  lumhricoides,  giving  rise  to  "Ascariasis." 

2.  Oxularis  vermicularis,  or  threadworms. 

3.  Trichina,  giving  rise  to  "Trichiniasis." 

4.  Ankylostomia,  causing  hookworm  disease  (elsewhere 
described). 

5.  Filiarice  (elsewhere  described). 

ASCARIASIS. 

Ascariasis  is  due  to  infestation  by  the  Ascaris  lumhricoides, 
a  very  common  parasite,  resembling  very  much  the  ordinary 
earth-worm,  except  that  it  is  much  lighter  in  color.  It  is  much 
more  common  in  children,  but  may  be  found  in  any  age.  Not 
only  is  this  the  most  common  worm  that  infests  human  beings, 
but  it  also  yields  more  readily  to  treatment.  Usually  these 
worms  are  not  numerous,  but  consist  of  only  one  or  two,  at 
each  infestation. 

Symptoms  may  be  absent.  Sometimes  the  first  evidence 
of  their  presence  is  their  appearance  in  the  stool  or  in  the 
vomitus.  The  symptoms  upon  which  the  laity  lay  much 
stress  are  picking  of  the  nose  and  stomachache.  These  symp- 
toms, however,  if  they  are  due  to  worms  at  all,  are  simply  due 
to  the  indigestion  which  they  cause,  and  may  be  present  in  any 
kind  of  indigestion.  Without  the  knowledge  of  the  worm 
being  seen  either  in  the  stool  or  the  vomitus,  or  the  knowledge 
gained  by  the  presence  of  the  ova  in  the  stool,  children  (who 
are  the  ones  most  frequently  infested)  should  never  be  given 
vermifuge  medicine.  These  worms  may  give  rise  to  nervous 
manifestations,  such  as  convulsions.  They  have  been  known 
to  cause  jaundice  by  plugging  the  common  duct. 


OXYURIS    VERMICULARIS.  137 

TREATMENT. 
In  beginning  treatment  for  round-worms  it  is,  perhaps, 
wise  to  put  the  children  on  a  light  diet  and  give  them  a  purge 
of  castor  oil  or  citrate  of  magnesia.  This,  however,  is  not  an 
absolute  necessity.  The  drug  which  is  absolutely  a  specific 
against  round-worms  is  santonin.  This  drug  may  be  given  in 
1-grain  (0.065  Gm.)  doses  three  times  a  day  for  three  successive 
days,  and  then  followed  by  a  dose  of  calomel.  I'  think  this  is 
much  better  than  giving  the  santonin  combined  with  calomel,  be- 
cause if  the  calomel  is  given  with  the  vermifuge,  the  bowels 
are  moved  rather  frequently,  and  the  drug  does  not  get  an 
opportunity  to  come  in  contact  with  the  worm.  The  stools 
should  be  carefully  watched  after  this  treatment,  and  if 
neither  ova  or  worm  appear  in  the  stool,  it  should  be  repeated. 
The  only  untoward  result  of  this  dose  of  santonin  is  occasion- 
ally a  yellow  vision,  which  is  simply  annoying  and  has  no 
serious  import.  Further  infestion  can  be  prevented  by  care- 
fully washing  the  hands  and  manicuring  the  nails  when  they 
have  come  in  contact  with  the  anus. 

OXYURIS    VERMICULARIS. 

These  tiny  worms,  which  appear  at  the  anus,  give  rise  to 
itching,  and  in  females  they  creep  into  the  vulva  and  vagina 
and  cause  a  vaginitis.  Occasionally  these  worms  have  been 
found  in  the  vermiform  appendix,  that  organ  under  such  con- 
ditions being  quite  a  large  tumor  packed  with  these  tiny 
worms. 

General  symptoms  are  very  uncommon,  the  chief  one  being 
pruritus  ani.  There  are  cases  on  record,  however,  where  the 
worm  has  penetrated  the  wall  of  the  gut  and  given  rise  to 
pericecal  abscess.  The  worms  develop  in  the  small  intestine, 
and  then  gravitate  to  the  cecum,  from  which  place,  after  the 
female  worm  has  become  gravid,  they  appear  at  the  anus.  The 
longevity  of  these  worms  is  important  in  the  treatment,  be- 
cause if  one  administers  remedies  simply  to  remove  the  worms 
from  the  lower  bowel,  there  will  very  soon  be  a  reappearance 
of  the  worm  at  the  anus,  because  the  source,  the  actual  origin, 
has  not  been  touched  by  these  local  applications  to  the  rec- 
tum.   The  best  method  of  treatment,  it  seems  to  the  writer,  is 


138  SPECIFIC    INFECTIONS. 

first,  to  remove  the  worms  from  the  anus  and  rectum,  and  then 
immediately  direct  one's  treatment  to  the  adult  worms  in  the 
small  or  large  intestine. 

Local  applications  to  the  rectum  of  chlorid  of  sodium, 
(ordinary  table  salt),  dissolved  in  water,  or  the  injection  of  a 
decoction  of  quassia  are  quite  efficacious  in  removing  these 
adult  worms  from  the  rectum.  The  decoction  of  quassia  may 
be  made  by  directing  the  patient  to  purchase  at  the  drug  shop 
1  ounce  or  2  ounces  (31.1  or  62.2  Gms.)  of  quassia  chips,  put- 
ting them  in  a  pint  of  water  and  boiling  to  a  half-pint  (236 
mils),  and  then  using  2  or  3  ounces  (60  or  90  mils)  of  this  as 
an  injection.  This  in  a  day  or  two  will  remove  all  the  worms 
from  the  rectum. 

Reinfection  plays  a  very  large  part  in  the  persistence  of 
these  small  parasites,  and  therefore  every  individual  who  is 
infested  with  Oxyu7'is  vermiciilaris  should  be  provided  with  a 
tight  muslin  drawer  withouU  an  opening  at  the  genital  parts. 
This  prevents  the  child  from  scratching  his  anus  when  he  is 
asleep  or  when  he  is  awake  and  conveying  the  ova  of  the  worm 
by  his  soiled  fingers  to  liis  mouth  where  they  are  swallowed. 
Without  this  precaution  the  treatment  of  pin-worms  is  almost 
an  interminable  affair.  For  the  destruction  of  the  worms,  in 
the  intestine  itself,  the  administration  of  santonin,  exactly 
after  the  manner  it  is  administered  in  round-worms,  is  bene- 
ficial. Thymol  has  been  used  and  is  efficacious,  but  in  the 
opinion  of  the  writer  is  not  the  remedy  of  choice. 

TRICHINIASIS. 

The  adult  worm,  or  Trichincc,  lives  in  the  intestine  of  man, 
and  gives  rise  to  gastro-intestinal  symptoms — diarrhea  and  in- 
testinal discomfort.  But  this  intestinal  implantation  is  a  small 
part,  although  a  constant  one,  of  the  danger  of  trichinae.  The 
intermediary  host  is  the  hog.  Hogs  harbor  the  larvse  of  the 
trichinse  in  their  flesh ;  the  flesh  in  this  condition,  uncooked,  is 
entirely  unfit  for  man ;  thus  the  larvae  are  swallowed,  and  in  a 
very  short  time  the  adult  trichinae  develop  in  the  human  in- 
testines. This  is  the  first  stage  of  trichiniasis.  The  females, 
containing  many  thousand  of  living  embryo,  pierce  the  intes- 
tinal canal  and  probably  deposit  their  embryo  directly   into 


TRICHINIASIS.  139 

the  blood  and  lymph-channels  en  route.  From  the  blood-ves- 
sels and  lymph-channels,  the  embryo  invade  the  various  por- 
tions of  the  body,  particularly  in  the  muscles,  where  they  give 
rise  to  certain  symptoms  to  be  later  described ;  they  become 
encysted  in  a  spiral  form,  and  finally  in  the  last  stag'e,  when 
they  are  entirely  quiescent,  become  calcified. 

The  whole  cycle  of  Triclnncc,  as  given  by  Stiles  is  as  follows: 
Firjt,  man  obtains  trichiniasis  from  eating  pork ;  second,  hogs 
become  infested  from  uncooked  swill  containing  scraps  of  pork 
and  from  rats ;  rats  obtain  their  infestion  from  eating  each 
other,  and  eating  scraps  of  pork  in  houses  or  meat  shops. 
Rats  alone,  swine  alone,  or  rats  and  swine  together  may  keep 
up  an  endless  chain  of  infestation.  The  infestation  which 
reaches  man  may  terminate  through  the  death  of  the  in- 
dividual. Accordingly,  man  must  be  viewed  as  a  more  or  less 
accidental  host,  while  the  rat,  because  of  its  cannibalistic 
habits,  presents  theoretically  ideal  conditions  as  the  normal 
liost. 

After  the  uncooked  pork  containing  the  live  larvje  is  eaten, 
there  is  a  period  of  quiescence  lasting  from  several  hours  to  a 
few  days,  and  this  is  followed  in  severe  cases  by  digestive 
symptoms — vomiting,  pain  in  the  abdomen,  sometimes  diar- 
rhea, although  these  initial  symptoms  may  be  entirely  absent. 
Within  a  day  or  two  after  the  onset  of  gastro-intestinal  symp- 
toms, the  patient  develops  fever,  which  may  range  as  high  as 
104°  or  105°  F.  (40°  or  40.5°  C).  This  temperature  range  re- 
sembles closely  the  temperature  of  typhoid  fever,  and  in 
sporadic  cases,  is  very  apt  to  be  mistaken  for  that  disease. 
The  muscles  become  sore,  swollen  and  tender,  the  patient  be- 
comes restless  and  very  much  disturbed.  If  the  lungs  are 
affected,  there  may  be  urgent  dyspnea.  If  the  infestation  is 
very  severe,  the  patient  may  die  of  exhaustion  and  fever. 

The  blood  of  an  individual  infested  with  trichinae  is  ver}^ 
characteristic;  there  is  a  high  leucocytosis,  Dr.  A.  H.  ^^lellersh 
and  the  writer  having  described  1  case  in  which  a  count  of 
32,000  leucocytes  and  an  eosinophilia  of  23  per  cent,  were 
present.  The  combination  of  high  fever  leucocytosis  and 
eosinophilia,  is  quite  characteristic  of  trichiniasis,  although,  as 
Da.  Costa  has  shown,  eosinophilia  is  not  present  in  cases  of 
decided   chronicity.     When   these    symptoms   present   them- 


140  SPECIFIC    INFECTIONS. 

selves,  a  small  bit  of  the  muscle  should  be  excised,  and  search 
made  for  the  trichinae.  The  presence  of  the  trichinje  in  the 
muscle,  will  of  course  establish  the  diagnosis.  If  these  cases 
occur  in  groups,  after  a  repast  or  a  picnic  of  some  sort,  where 
uncooked  pork  has  been  used,  trichiniasis  is  naturally  sus- 
pected, and  the  diagnosis  very  easily  made. 

Prevention  in  this  disease  is  the  most  important  part  of 
the  treatment.  Care  must  be  taken  that  no  pork  is  sold  that 
contains  trichinae.  This,  of  course,  should  be  done  under  gov- 
ernment supervision.  As  Osier  points  out,  this  would  be  a  very 
expensive  and  tedious  operation,  and  perhaps  would  not  be 
practicable  in  this  country.  On  the  other  hand,  if  everyone 
would  be  careful  and  eat  no  pork  except  it  be  thoroughly 
cooked,  this  in  itself  would  make  trichiniasis  an  unknown 
disease. 

TREATMENT. 

When  the  case  is  seen  in  the  very  early  stages,  and  intes- 
tinal symptoms  are  present,  a  brisk  purge  should  be  given,  in 
order  to  drive  as  many  of  the  adult  worms  as  possible  from 
the  intestine.  Even  if  one  female  adult  is  removed  from  the 
intestinal  tract,  this  probably  will  prevent  hundreds  of  larvae 
from  entering  the  circulation.  Santonin  and  thymol  must  be 
given,  to  kill  the  adult  worms.  After  the  larvae  have  entered 
the  muscles,  the  treatment  must  be  entirely  symptomatic; 
warm  applications,  tepid  bathing  when  the  temperature  is  high, 
and  supportive  measures  are  methods  worthy  of  use.  The 
author  has  thought  that  probably  the  administration  of  neo- 
salvarsan,  when  the  larvae  have  entered  the  blood-vessels  might 
be  of  some  value. 

PARASITIC  INSECTS. 

PARASITIC    ARACHNIDIA. 

This  troublesome  insect  in  this  affection,  known  as  the  itch 
mite,  gives  rise  to  very  many  annoying  symptoms,  although 
perhaps  never  fatal.  Itching  is  the  chief  symptom.  Infection 
by  this  insect  is  extremely  common  in  India. 

Usually  there  is  herpes  due  to  the  first  implantation  of  the 
insect.     From  these   herpetic  areas  the   mite  burrows  uncjer 


PARASITIC   INSECTS.  141 

the  skin,  making'  tracks,  which  contain  at  the  end  the  itch  mite. 
This  is  the  male,  the  female  being-  rarely  found.  The  individ- 
ual infested  scratches  himself,  giving-  rise  to  scratch  marks 
which  become  infected,  sometimes  causing-  large  ulcerating 
areas. 

TREATMENT. 

The  important  point  in  the  treatment  of  these  cases  is  the 
diagnosis.  Very  frequently  real  itch,  particularly  as  it  occurs 
in  unclean  persons,  is  taken  for  all  sorts  of  skin  diseases. 

The  treatment  is  exceedingly  simple.  A  hot  bath  should 
be  given  and  repeated  every  day,  and  the  afifected  parts  rubbed 
with  precipitated  sulphur,  20  grains  (1.3  Gm.)  of  sulphur  to 
an  ounce  (31.1  Gm.)  of  a  simple  ointment.  Not  only  should 
the  parts  of  the  body  where  the  eruption  is  seen  be  rubbed 
with  this  ointment,  but  all  the  portions  of  the  body  where  the 
skin  is  thin,  should  also  be  anointed,  particularly  the  skin  of 
the  thighs  and  under  the  arms. 

IXODIASIS    (TICK    DISEASE). 

Quoting  from  Osier  the  entire  paragraph  in  his  "Practice 
of  Medicine":  'Tn  South,  Africa,  particularly  in  the  western 
provinces  of  the  Uganda  Protectorate,  western  districts  of 
German  East  Africa,  and  the  eastern  regions  of  the  Congo 
Free  States,  there  is  a  disease  known  by  this  name  believed  to 
be  transmitted  by  a  tick,  Oniitlwdorous,  or  Argas  Monhata. 
Christy  states  that  the  bites  of  the  O.  savignyi  do  not  produce 
any  ill  effects.  The  ticks  live  in  old  houses,  and  their  habits 
are  very  much  like  those  of  the  common  bed  bug.  This  tick 
transmits  the  Spirochccta  diittoni,  the  cause  of  the  African  form 
of  relapsing  fever." 

The  Spotted  Fever  of  Montana  and  California,  Rocky 
Mountain  Spotted  Fever,  is  caused  by  a  tick,  Dcvmaccntor 
occidcntalis. 

Pediculosis;  Phtliiriasis.  These  pediculi  are  of  great  impor- 
tance, and  particularly  since  it  has  been  discovered  that  ty- 
phus fever  is  transmitted  solely  by  the  body-louse. 

Pediculosis  is  due  to  the  Pediculits  capitis,  insects  which  in- 
habit the  heads  of  uncleanly  individuals.  Sometimes  they  are  in 
immense  numbers.    One  patient  presented  himself  in  the  Out- 


142  SPECIFIC   INFECTIONS. 

Patient  Department  of  the  University  of  Pennsylvania,  in  whom 
the  hair  of  the  head  was  actually  teeming  with  thousands  of  head- 
lice,  and  yet  this  patient  apparently  had  no  knowledge  as  to 
what  was  the  matter.  The  ova  of  these  insects  are  contained 
in  little  sacs,  called  "nits,"  which  are  attached  to  the  root  of  the 
hair  by  gelatinous  material.  They  can  be  differentiated  from 
the  bits  of  dandruff  and  other  foreign  material  by  the  fact  that 
they  are  tightly  adherent  to  the  hair,  and  if  put  under  a  low- 
powder  microscope  they  are  seen  to  be  animal  material,  and 
when  crushed,  eggs  will  be  seen  in  their  contents. 

Very  frequently,  when  there  are  not  very  many  of  the  lice 
present,  they  are  more  numerous  near  the  nape  of  the  neck, 
and  an  ulceration  in  this  area,  due  to  scratching,  is  a  very 
suspicious  sign  that  the  head  is  infested  with  lice.  If  the  hair 
be  carefully  examined  in  this  condition,  the  lice  or  nits  will 
be  discovered. 

The  treatment  of  the  head-louse  is  very  simple.  The  hair 
should  be  shaved  when  the  insects  are  very  numerous,  the 
whole  scalp  washed  with  coal  oil,  and  enveloped  in  a  gauze 
bandage  for  some  hours.  This  will  effectually  kill  all  of  the 
nits.  Even  after  this  treatment  has  been  administered,  scrupu- 
lous care  must  be  taken  that  reinfestation  does  not  occur. 
There  is  perhaps  nothing  more  disturbing  to  a  well  regulated 
household  than  to  see  a  child  come  home  from  school  with  a 
number  of  head  lice.  In  these  small  infestations,  it  is  not 
necessary  to  actually  cut  the  hair  off,  but  by  careful  combing 
and  destroying'  all  the  nits,  and  then  using  a  solution  of  car- 
bolic acid,  1  to  SO,  or  bichlorid  of  mercury,  1  to  500,  on  the  hair, 
the  insects  and  nits  will  likewise  be  destroyed. 

Pediculus  Corporis.  This  louse  is  larger  than  the  head- 
Icuse ;  it  is  of  particular  importance  because  of  its  relation  t(? 
typhus  fever.  It  has  now  been  shown  that  without  the  louse 
there  would  be  no  typhus  fever.  These  body-lice  attach  them- 
selves to  the  clothing,,  and  therefore  the  best  way  to  destroy 
them  is  to  destroy  the  clothing  by  burning  or  by  disinfecting  it 
under  hot  steam.  Often  the  body  is  covered  with  scratch- 
marks,  sometimes  with  ulcerations,  the  result  of  infection  of 
said  scratch-marks.  The  itching,  which  is  the  result  of  the 
bite  of  these  insects,  can  be  controlled  by  warm  baths,  and  by 
inunction  of  the  body  with  carbolic  acid  ointment  or  by  the  ap- 


PARASITIC    INSECTS.  143 

plication  of  carbolic  solution,  1  to  20,  or  bichlorid  of  mercury, 
1  to  1000. 

The  Pediculus  pubis  is  an  insect  somewhat  smaller  than  either 
of  the  other  lice,  and  inhabits  those  portions  of  the  body  where 
tlie  hair  is  short,  principally  the  pubis  and  under  tlie  arm-pits. 
Pubic  lice  are  usually  an  indication  that  the  individual  has  had 
some  intercourse  with  another  individual  wdio  is  uncleanly  in 
his  habits. 

The  treatment  is  shaving-  the  pubic  hair  and  pubis,  shaving 
out  the  axillary  hair  and  anointing-  the  axillae  and  pubes  with 
mercurial  ointment.  One  must  not  be  satisfied  with  shaving 
the  hair  and  applying  the  mercurial  ointment,  but  must  wash 
the  parts  thoroughly  in  warm  water. 

CIMEX    LECTULARIUS. 
(Common  Bedbug). 

This  insect  lives  in  bedsteads  which  are  not  kept  clean 
and  in  cracks  of  boarding  about  old  houses  which  have  been 
allowed  to  become  unsanitary. 

To  some  individuals  they  cau'se  a  great  deal  of  annoyance, 
and  others  are  not  affected  by  a  bite.  Any  bedstead  or  room 
which  is  infested  with  these  insects,  can  be  thoroughly 
cleansed  by  fumigating  the  room  with  sulphur,  and  taking  the 
bedsteads  apart  and  cleansing  them  with  coal  oil. 

PULEX    IRRITANS. 

(Common  Flea). 

These  are  very  common  in  certain  districts,  particularly  in 
Italy,  where  practically  everyone  is  bitten  by  fleas. 

They  give  rise  to  no  serious  symptoms,  but  cause  some 
irritation,  and  sometimes  urticaria. 

PULEX    PENETRANS. 
(Sand  Flea,  Jigger). 

This  little  insect  is  found  in  the  AA'est  Indies,  particularly, 
where  it  bites  and  burrows  under  the  skin.  It  gives  rise  to  no 
serious  symptoms  and  may  be  removed  very  easily  by  a  needle. 


144  SPECIFIC   INFECTIONS. 

PARASITIC    FLIES. 

(Myiasis,  Myiosis). 

The  larvae  of  various  flies  have  been  found  in  different  por- 
tions of  the  body.  A  few  worms  or  larvse  of  the  LuciHa  macel- 
laria,  are  often  found  in  the  nose  and  in  wounds,  and  some- 
times in  the  vagina. 

Treatment  consists  in  the  removal  of  the  larvse  by  forceps. 
Larvse  of  many  different  flies  have  been  found  in  intestinal 
contents  and  in  vomitus.  They  very  rarely  g'ive  rise  to  any 
serious  symptoms,  although  almost  all  the  individuals  so 
afflicted  complain  of  having  "something  alive"  in  their  stom- 
ach, or  in  their  intestine. 

RABIES. 

Hydrophobia  is  transmitted  to  man  by  the  bite  of  various 
lower  animals,  particularly  dogs,  wolves  and  cats. 

The  disease  is  transmitted  by  the  saliva  with  which  the 
wound  is  contaminated  when  the  individual  is  bitten.  The 
bites  are  more  frequently  followed  by  the  disease  when  they 
are  on  the  bare  surfaces,  such  as  on  the  hands  and  on  the  face. 
When  the  bites  are  through  the  clothing,  relatively  few  in- 
dividuals develop  the  disease. 

The  period  of  incubation  varies  greatly,  averaging  perhaps 
from  one  to  two  months.  After  a  person  has  been  bitten  by 
a  rabid  dog,  the  first  symptoms  are  signs  of  irritation  around 
the  wound.  The  patient  becomes  nervous,  irritable,  and  often 
introspective.  Then  there  is  irritation  about  the  larynx,  the 
patient  often  having  difficulty  in  swallowing  liquids.  Soon 
any  attempt  to  swallow  liquid  is  followed  by  the  character- 
istic respiratory  spasm.  If  the  patient  is  thirsty  and  attempts 
to.  drink,  he  tosses  the  liquid  into  the  back  of  his  throat,  and 
at  once  goes  into  an  apnoeic  condition  due  to  failure  of  the 
respiration,  caused  by  a  spasm  of  the  respiratory  muscles. 
Not  only  does  the  attempt  to  swallow  liquids  bring  on  these 
spasms,  but  a  sudden  noise,  or  being  disturbed  by  a  visitor,  or 
a  draft  blowing  on  the  patient  may  precipitate  an  attack.  The 
temperature  rises;  the  patient  often  becomes  cyanotic,  thresh- 
ing about  the  bed,  and  convulsions  ensue.    Toward  the  end 


RABIES.  145 

the  individual  becomes  paralyzed,  lies  quiet,  and  usually  dies 
in  coma. 

TREATMENT. 

Prophylaxis  is  the  most  important  part  of  the  treatment. 
The  methods  to  be  followed  are  as  follows :  Immediately 
upon  the  patient  being-  bitten  by  a  rabid  dog",  the  wound 
should  be  thoroughly  cauterized  by,  first,  an  incision  opening 
the  wound  widely,  and  then  the  use  of  a  hot  iron  or  nitric 
acid  directly  into  the  opened  wound,  the  patient  being-  anes- 
thetized. This  same  cauterization  should  be  done  on  every 
wound  made  by  a  vicious  animal,  supposed  to  be  rabid.  The 
animal  should  be  then  confined,  and  on  the  first  appearance 
of  rabies  in  the  animal  the  stricken  individual  should  be  given 
preventative  inoculations  or  Pasteur  treatment.  Many  State 
boards  of  health  now  examine  gratis  the  nerve-centers  of  ani- 
mals suspected  of  rabies.  The  dog  is  killed,  the  head  severed 
from  the  body,  packed  in  ice  or  other  refrigerating  material, 
and  shipped  to  the  authorities.  In  the  State  laboratories  the 
ganglia  are  examined.  A  certain  diagnosis  for  or  against 
rabies  can  thus  be  made,  and  treatment  begun  sooner  than  it 
can  be  if  symptoms  of  rabies  in  the  dog  are  waited  for.  This 
virus  may  now  be  purchased  from  almost  any  of  the  biological 
chemists,  and  from  the  New  York  Board  of  Health.  The 
virus  is  sent  to  the  physician  in  syringes  or  other  containers, 
which  may  be  used  by  anyone,  even  though  he  is  not  accus- 
tomed to  the  treatment.  Pasteur  treatment  is  based  upon  the 
fact  that  the  virus  of  rabies  concentrates  itself  in  the  nervous 
centers  of  animals  sick  with  the  disease.  Rabbits  are  inocu- 
lated with  the  virus ;  when  they  develop  rabies  they  are  killed ; 
the  spinal  cord  is  removed  aseptically,  and  dried  over  caustic 
potash.  Then  this  infected  cord  is  emulsified,  proved,  and  sent 
to  the  physician  in  the  containers.  The  older  cords  are  sent 
first,  then  daily  doses  are  sent  rapidly  approaching  the  cord 
of  one  day.  The  contents  of  these  containers  is  injected 
hypodermatically.  Very  few  patients  develop  rabies  after 
these  prophylactic  measures. 

The  cure  of  hydrophobia  after  the  paroxysms  have  begun 
is  entirely  hopeless.  The  treatment  should  be  directed  to  the 
control  of  the  parox3^sms.  This  may  be  done  by  the  adminis- 
tration of  chloroform,  or  keeping  the  patient  under  the  influ- 

10 


146  SPECIFIC   INFECTIONS. 

ence  of  morphin  and  chloral  and  bromid  of  potassium,  and 
making-  his  miserable  existence  as  comfortable  as  possible. 
He  should  be  in  a  darkened  room,  and  with  very  few  visitors. 
The  nurse  should  be  carefully  clothed  in  a  gown,  have  her 
hands  encased  in  gloves,  being  careful  not  to  inoculate  any 
abrasion  with  the  saliva  of  the  patient. 

PSITTACOSIS. 

This  is  an  infectious  disease  transmitted  to  man  from 
birds,  and  particularly  from  parrots.  According  to  those 
familiar  with  the  disease,  it  resembles  typhoid  fever  compli- 
cated with  pneumonia.  The  diagnosis  from  typhoid  fever  can 
be  made,  however,  by"  the  absence  of  the  Widal  reaction  and 
a  negative  blood  culture  for  typhoid  bacilli.  It  is  certain  that 
this  severe  disease,  with  rather  a  high  mortality,  has  occurred 
in  epidemic  form  in  houses  whose  occupants  have  been  owners 
of  various  feathered  pets,  notably  parrots. 

The  treatment  according  to  Boggs  is  the  following: 

TREATMENT. 

"In  view  of  the  possible  agency  of  the  parrot  in  conveying 
this  infection,  the  handling  of  the  sick  birds  should  be  dis- 
couraged. Cleanliness  and  disinfection  of  the  cages  should  be 
carefully  observed.  The  patients  should  be  isolated  as  a  pre- 
cautionary measure.  Tub  baths  and  cold  packs  are  highly 
recommended  by  the  French  observers,  who  treat  the  cases 
throughout  like  typhoid  fever." 

MILK    SICKNESS. 

Milk  sickness,  or  "trembles,"  as  it  is  called,  is  a  disease 
transmitted  to  man  from  cattle,  sick  with  this  disease. 

The  disease,  as  said,  is  primary  in  cattle,  and  is  due  to  the 
Bacillus  lactimorbi. 

The  symptoms  in  man  are  weakness  and  loss  of  appetite, 
soon  followed  by  gastro-intestinal  symptoms — vomiting,  diar- 
rhea, and  abdominal  pain.  The  breath  has  a  sweetish  odor, 
the  tongue  becomes  swollen,  the  pulse  is  quick  and  full,  and 


FOOT-AND-MOUTH    DISEASE.  147 

there  are  marked  nervous  symptoms,  the  result  of  the  toxe- 
mia, convulsions  and  delirium  being  very  common.  The  cases 
are  remarkably  fatal  in  man. 

TREATMENT. 

The  important  point  in  the  treatment  is  prevention.  As 
this  disease  is  always  transmitted  from  cattle,  care  should  be 
taken  that  the  milk  of  the  cows,  or  the  flesh  of  any  of  the  ani- 
mals affected  by  trembles  is  not  used. 

The  treatment  is  entirely  symptomatic.  The  patient 
should  be  in  bed.  and,  if  the  fever  is  high,  hydrotherapy 
should  be  used.  Magnesium  sulphate  and  castor  oil  should 
be  used  as  purgatives  to  clean  out  the  intestine  of  the  infected 
milk. 

Bromid  of  potassium,  for  the  nervous  symptoms,  is  use- 
ful. An  abundance  of  water,  by  the  mouth,  by  the  rectum  in 
the  form  of  Murphy  drip,  and,  if  necessary,  by  intravenous 
injection  of  normal  salt  solutions. 

FOOT-AND-MOUTH    DISEASE. 

This  disease,  occurring  in  cattle,  sheep  and  hogs,  is  trans- 
mitted from  these  animals  to  men  direct,  apparently  by  trans- 
mission. 

The  affected  cattle  rapidly  lose  flesh,  and  become  feverish, 
vesicles  occur  along  the  edges  of  the  tongue,  and  desquama- 
tion of  the  entire  tongue,  often  in  large  patches,  sometimes 
of  the  entire  tongue,  is  common.  In  cows  there  are  vesicles 
on  the  udders  and  on  the  teats,  and  there  is  profuse  salivation. 
The  mortality  is  not  high  in  cattle,  but  often  whole  herds  are 
ordered  slaughtered  in  order  to  prevent  an  epidemic  of  this 
disease  from  spreading. 

During  the  course  of  the  disease  men  sometimes  become 
infected,  and  show  exactly  the  same  symptoms  as  the  cattle ; 
they  have  ulcers  in  the  throat  and  on  the  tongue,  with  fever 
and  emaciation.  Usually  the  cases  are  not  fatal,  but  some- 
times there  is  considerable  toxemia,  and  in  one  epidemic 
quoted  by  Osier  there  were  eighteen  deaths.  When  an  epi- 
demic prevails  in  cattle,  the  milk  should  be  boiled.  It  is  not 
thought  that  the  meat  of  infected  cattle  transmits  the  disease. 


148  SPECIFIC  INFECTIONS. 

TREATMENT. 

The  methods  of  treatment  recommended  in  man  by  Boggs 
is  to  isolate  the  patient,  and  to  apply  local  remedies  to  the 
ulcers.  Permanganate  of  potassium  is  recommended  as  a 
mouth-wash.  The  ulcers  may  be  touched  with  silver  nitrate, 
or  with  copper  sulphate.  Drying-  powders  may  be  applied  to 
the  external  lesions.  Special  attention  is  given  to  the  diet, 
and  in  severe  cases  and  in  young  children  feeding  by  a  nasal 
tube,  a  stomach-tube,  or  rectal  enemata  may  be  indicated. 

INFECTIOUS    COLDS. 

Unquestionably  so-called  colds  are  an  infection  due  to  one 
or  the  other  of  several  micro-organisms. 

The  Micrococcus  catarrhalis,  which  affects  the  mucous 
membrane  of  the  nose  particularly,  has  been  cited  as  the 
causative  factor  of  many  of  these  attacks,  but  cases  which  are 
indistinguishable,  except  by  cultural  methods,  are  found  due 
to  the  pneumococcus,  the  influenza  bacillus,  and  to  other 
micro-organisms. 

The  symptoms  of  these  colds  are  chilly  sensations,  coryza, 
lachrymation,  short  hacking  cough,  and  a  laryngitis,  together 
with  aching  of  the  limbs  and  headache.  Here,  again,  there 
is  danger  of  considering  these  infectious  colds  nothing  but 
colds,  and  hence  treating  them  lightly,  when  as  a  matter  of 
fact  they  may  be  the  premonitory  symptoms  of  measles,  or 
of  bronchitis,  which  ma}^  run  on  to  a  serious  proportion,  and, 
indeed,  to  almost  any  infection  of  the  respiratory  tract. 

It  is  difficult  to  have  our  patients  obey  the  order  "to  bed" 
in  these  light  attacks,  but  certainly  that  is  a  measure  of  safety, 
and  it  should  be  advised  to  all  our  patients  thus  affected. 

TREATMENT. 

Rest  in  bed,  with  the  rooms  well  ventilated,  or  even  in 
the  open  air,  the  patient  being  well  protected,  is  the  most 
important  of  all  of  the  points  of  treatment.  The  coryza  may 
be  controlled  to  a  certain  extent  by  the  use  of  some  alkaline 
spray,  such  as  Dobell's  solution,  or  a  normal  salt  solution. 
Adrenalin  chlorid  solution,  1  to  2000,  may  be  sprayed  in  the 


MILIARY   FEVER.  149 

nostrils,  and  often  will  give  quite  instant  relief.  The  same 
application  may  be  made  to  the  throat.  The  aching  is  best 
controlled  by  one  of  the  salicylates,  acetylsalicylic  acid  or 
aspirin  being  the  choice  of  the  writer.  Phenol  salicylate  or 
salol  is  another  excellent  drug;  or  a  combination  of  phenol 
salicylate  and  phenacetin  is  comforting,  and  often  in  a  few 
hours  will  convert  a  very  uncomfortable  individual  to  one 
who  feels  badly,  but  is  not  very  acutely  ill.  This  combina- 
tion should  be  given  in  5-grain  (0.32  Gm.)  doses  of  each  drug, 
repeated  every  two  hours,  and  continued  for  at  least  twenty- 
four  hours.  The  headache  and  fever  are  also  controlled  by 
this  medication. 

If  the  cough  is  dry  and  hacking,  small  doses  of  an  opiate, 
such  as  paregoric,  will  often  control  it  so  that  the  patient  gets 
comfort  and  rest,  instead  of  being  uncomfortable  and  cough- 
ing. 

The  bowels  should  be  opened  by  small  doses  of  calomel, 
YiQ  of  a  grain  (0.006  Gm.)  every  half-hour  until  a  grain  (0.065 
Gm.)  is  taken,  or  a  saline,  such  as  citrate  of  magnesia.  Cocain  is 
mentioned  in  order  that  it  may  be  avoided.  It  is  a  very  dan- 
gerous habit  to  give  these  patients  a  spray  of  cocain  for  the 
nose,  for  many  cocain  habitues  have  been  made  in  this  way. 

MILIARY    FEVER. 

This  disease  has  been  known  for  centuries,  and  in  the  early 
fifteenth  and  sixteenth  centuries  was  quite  a  fatal  disease, 
particularly  in  England.  At  present  it  seems  to  be  limited  to 
very  slight  local  outbreaks,  particularly  in  SAvitzerland,  and 
lately  epidemics  in  Austria  have  been  reported. 

It  is  a  disease  characterized  by  sudden  onset,  high  fever, 
and  a  remarkable  amount. of  sweating,  the  sweat  continuing 
with  the  fever,  and  throughout  the  entire  course  of  the  illness. 

The  temperature  ranges  from  102°  to  103°  F.  (38.8°  to 
39.4°  C.).  The  heart  is  rapid,  palpitation  being  one  of  the 
symptoms  which  annoy  the  patient.  Nervous  symptoms — 
delirium  and  coma — are  very  common.  The  eruption  is  best 
described  by  Boggs : 

"The  eruption  appears  on  the  third  or  fourth  day,  and  is 
seen  first  on  the  neck  and  back,  under  the  breasts  and  axillae. 


150  SPECIFIC   INFECTIONS. 

and  between  the  thig-hs.  A  general  erythema  is  present,  in 
addition  to  which  appears  (a)  sudamina  (miliaria  alba  or 
crystallina),  (b)  red  papules  becoming  vesicular  (miliaria 
rubra),  (c)  petechise  of  variable  size  (purpura  miliaria).  The 
appearance  of  the  eruption  is  preceded  by  itching.  The  red 
papulovesicular  type  is  most  frequently  observed,  with  usually 
some  sudamina;  the  purpuric  type  is  not  seen  so  often,  and 
occurs  in  the  cases  with  other  hemorrhagic  manifestations. 
Vesicles  are  also  frequently  found  on  the  mucous  membranes 
of  the  conjunctiva,  nose  and  mouth.  The  rash  may  come  out 
rapidly,  and  cover  the  whole  body  in  twenty-four  hours,  or 
slowly,  and  in  successive  crops.  The  desquamation  may  be 
advanced  in  the  regions  first  affected,  while  other  areas  show 
the  early  stages." 

The  treatment  is  entirely  symptomatic.  The  patient 
should  be  in  bed.  Hydrotherapy  should  be  practised,  and 
the  patient  should,  of  course,  be  isolated.  On  account  of  the 
extreme  sweating  throughout  the  entire  course  of  the  disease, 
the  clothing  of  the  patients  has  to  be  repeatedly  renewed  to 
keep  them  comfortable.  Notwithstanding  the  profuse  sweat, 
hydrotherapy  is  of  the  utmost  importance,  relieving  many  of 
the  symptoms  of  the  disease.  The  nervous  symptoms  can  be 
best  controlled  by  the  bromids  in  large  doses,  20  grains  (1.3 
Gms.)  every  two  or  three  hours  for  forty-eight  hours  at  a 
stretch.  When  the  delirium  is  violent,  the  patient  must  be 
controlled  by  morphin.  Atropin  has  been  used  to  control 
the  sweat,  without,  however,  very  much  effect. 

The  convalescence  is  often  prolonged.  The  patient  should 
take  an  abundance  of  food,  rest  and  fresh  air  during  the  entire 
convalescence. 


Exanthemata 


BY 

SAMUEL   S.   WOODY,    M.D., 

Chief  Resident  Physician,   Philadelphia  Hospital  for  Contagious 
Diseases. 


(151) 


Exanthemata. 


FOREWORD. 

In  the  management  of  contagious  diseases  the  phy- 
sician is  confronted  by  a  twofold  obligation — his  duty  to  the 
patient  and  his  duty  to  the  community. 

The  physician's  duty  to  the  patient,  of  course,  consists  of 
doing  everything  which  tends  to  recovery,  and  to  the  avoid- 
ance of  harmful  after-effects  of  the  disease  in  question. 

It  is  unfortunately  true  that,  with  the  exception  of  diph- 
theria, we  have  at  our  command,  in  no  instance,  a  remedy 
for  a  contagious  disease  which  is  in  any  sense  of  the  word 
specific.  On  the  other  hand,  in  the  most  widespread  and 
loathsome  of  all  the  contagious  exanthemata — smallpox — we 
have  a  certain  prophylactic  against  its  spread.  Vaccination 
against  smallpox  has  conferred  immunity  upon  millions  of 
people,  an  immunity  of  such  definiteness  and  length  of  dura- 
tion that  were  vaccination  universally  practised  smallpox 
would  be  unknown. 

The  physician's  duty  to  the  community  means  the  bending 
of  every  effort  to  avoid  the  spread  of  disease  from  his  patient 
to  other  persons.  This  is  not  a  matter  of  such  difficulty  as 
might  appear  if  all  possible  precautions  be  taken. 

With  the  exception  of  smallpox  and  chicken-pox,  it  is  very 
certain  that  the  contagious  diseases  are  not  often  air-borne ; 
even  in  these  instances  the  question  is  a  matter  of  some  doubt, 
but  we  are  not  without  evidence  that  there  may  be  such  a 
possibility. 

It  is  known  that  the  infection  of  all  of  the  exanthematous 
diseases  may  be  spread  by  an  intermediate  carrier.  Probably 
this  is  more  often  true  of  scarlet  fever,  diphtheria  and  small- 
pox than  of  the  other  contagious  diseases.  But  in  the  vast 
majority  of  instances  all  of  the  contagious  diseases  are  spread 
by  the  direct  communication  between  the  patient  and  some 
Other  individual  not  as  yet  infected. 

(153) 


154  EXANTHEMATA. 

In  order  that  the  physician  may  guard  against  the  spread 
of  contagion  not  only  are  the  foregoing  facts  of  the  utmost 
importance,  but  some  knowledge  of  the  location  of  the  in- 
fecting agent  in  the  diseased  person  himself  is  of  absolute 
importance.  In  other  words,  to  prevent  the  dissemination  of 
infectious  material  we  must  first  form  a  definite  idea  of  what 
this  material  is. 

Briefly,  our  knowledge  upon  this  important  subject  may 
be  summarized  as  follows,  stating  only  proven  facts  and  with 
no  regard  to  theoretical  considerations  of  infection : 

In  diphtheria  we  know  that  the  infecting  agent  can  reside 
in  the  discharges  from  the  site  of  the  lesion,  either  during 
the  active  process  of  the  disease  or  during  and  after  con- 
valescence. 

In  scarlet  fever  the  discharges  from  the  nose,  throat,  ears 
and  suppurating  glands  carry  the  active  infecting  agent,  which 
is  not  found  in  the  desquamating  skin. 

In  measles  the  discharges  from  the  nose,  throat  and  eyes 
are  infectious  during  the  stage  of  invasion,  and  while  the 
disease  is  at  its  height. 

The  infecting  agent  does  not  reside  in  the  chronic  aural 
or  nasal  discharges  of  a  case  of  measles.  It  is  known  also 
that  the  lesions  of  measles  harbor  the  virus  in  a  form  which 
permits  its  transmission.  The  virus  of  measles  is  extremely 
short-lived,  being  rarely  active  after  the  acute  stages  are 
passed. 

In  smallpox  and  chicken-pox  the  local  lesions  are  the  only 
demonstrable  locations  of  the  active  infecting  agent. 

With  these  facts  in  mind,  it  is  evident  that  effectual  isola- 
tion of  all  sufferers  from  contagious  diseases  and  the  isolation 
of  all  contacts  until  the  period  of  incubation  is  definitely  over 
would,  in  all  probability,  cause  a  practical  disappearance  of 
these  diseases. 

But  while  this  is  true  in  theory,  in  practice  it  is  a  matter 
of  the  utmost  difficulty  to  carry  out  preventive  measures 
based  upon  the  foregoing  premises.  For  this  there  are  a 
number  of  reasons. 

The  most  important  factor  in  preventing  the  quarantine 
of  contacts,  aside  from  the  disinclination  of  the  public  to 
submit  to  drastic  regulations,  is  the  contagiousness  of  these 


FOREWORD.  155 

diseases  before  the  specilic  lesions  manifest  themselves,  i.e., 
before  a  diagnosis  can  be  made.  This  being  the  case,  it  would 
seem  that  a  radical  suppression  of  these  diseases  in  their 
entirety  can  be  hoped  for  only  when  some  form  of  prophy- 
laxis, such  as  vaccination  for  smallpox,  is  found. 

When,  however,  the  disease  in  question  is  so  far  developed 
that  a  correct  diagnosis  is  possible,  isolation  of  the  patient  is 
of  the  greatest  importance  in  preventing  further  spread  of  the 
disease. 

There  is  no  doubt  that  treatment  in  a  special  hospital  is 
the  best  method  for  protecting  the  community  against  the 
spread  of  contagious  diseases,  but  this  is  not  always  possible. 
It  is  only  in  the  larg'er  communities  that  even  partly  ample 
facilities  are  at  hand. 

There  are  several  factors  in  the  handling  of  contagious 
diseases  that  furnish  us  our  basis  for  the  practical  solution 
of  the  problem  of  effectual  isolation. 

The  discharges  from  the  patient  carry  the  infecting  agent. 
Therefore,  our  first  problem  must  be  to  see  that  such  spread 
is  not  possible.  Bandages,  dressings,  gauze  used  for  hand- 
kerchiefs, etc.,  are  destroyed.  Other  articles  of  use  or  cloth- 
ing are  properly  sterilized.  Utensils  are  kept  for  the  patient 
only,  and  proper  precautions  are  taken  as  regards  their  free- 
dom from  infectious  material,  if  they  are  taken  from  the  sick- 
room itself. 

The  patient's  attendants  must  exercise  the  utmost  caution. 
The  nurse  should  be  isolated  with  the  patient  as  far  as  pos- 
sible. The  attending  physician  should  have  his  ordinary 
street  clothing  suitably  covered  when  he  enters  the  sick- 
room, and  this  covering  should  be  removed  upon  leaving  the 
room.  The  most  important  matter  of  all,  probably,  is  the 
care  of  the  hands.  Anyone  in  attendance,  on  leaving  the  sick- 
room, should  wash  his  or  her  hands  each  time,  and  the  phy- 
sician should  supplement  this  by  again  washing  his  hands 
before  approaching  the  next  patient. 

The  importance  of  fresh  air  and  ventilation  to  the  patient 
is  self-evident.  On  the  other  hand,  the  possibilit}'-  of  air  con- 
veyance of  contagious  diseases  is  sufficiently  great  to  cause 
us  to  take  certain  precautions  in  this  direction  also.  The 
sick-room  should,  by  perference,  not  open  directly  into  other 


156  EXANTHEMATA. 

occupied  rooms,  and  ventilation  should  be  from  outside  of  the 
house  rather  than  from  within. 

It  is  doubtful  in  the  extreme  whether  insects  carry  any  of 
the  contagious  diseases,  'but  to  avoid  all  possible  risks,  it  is 
proper  that  the  windows  of  the  sick-room  should  at  all  times 
be  properly  screened. 

The  value-  of  sterilization  of  clothes  and  utensils  after  a 
patient's  recovery  is  unquestionable,  as  is  also  the  necessity 
of  a  cleansing  bath  before  discharge. 

Fumigation  of  rooms  is  of  a  more  doubtful  status,  but  this 
should  be  employed  in  addition  to  subsequent  ventilation  for 
a  day  or  more. 

In  conclusion  it  may  be  remarked  that  the  physician  must 
be  guided,  not  only  by  his  own  opinion  upon  all  these  matters, 
but  should  always  follow  absolutely  the  rules  of  his  local 
health  authorities  in  the  management  of  all  the  details  of 
quarantine  and  preventive  steps. 

SMALLPOX. 

Smallpox  is  an  acute  contagious  disease,  characterized  by 
a  specific  eruption  and  fever. 

The  etiology  of  smallpox  is  unknown.  There  is  no  doubt 
that  the  disease  is  caused  by  a  micro-organism,  but  the  specific 
cause  has  not  as  yet  been  isolated.  The  virus  is  contained 
within  the  lesions  of  the  disease,  and  is  very  tenacious  of  life. 

The  mode  of  dissemination  of  smallpox  is  usually  by 
direct  contact  between  the  patient  and  a  non-immune  person, 
but  actual  contact  is  not  necessary  to  infection.  There  seems, 
however,  to  be  ample  evidence  that  the  disease  may  be 
carried  by  healthy  third  persons  and  by  fomites,  even  when 
a  long  time  has  elapsed  after  the  exposure.  The  disease  may 
be  contracted  by  merely  entering  a  room  or  building  in  which 
it  exists,  or  even  the  immediate  vicinity  of  the  building. 

Of  all  the  contagious  diseases,  smallpox  presents  the  best 
evidence  of  being  at  times  air-borne  and  of  occasional  con- 
veyance by  insects. 

Both  sexes  and  all  ages  are  prone  to  the  disease,  unless 
immunity  has  been  acquired  by  a  previous  attack  or  by  vac- 


SMALLPOX.  157 

cination.  The  latter  does  not  confer  absolute  immunity  for 
more  than  a  limited  time,  but  even  after  this  time  it  so  modi- 
fies an  attack  that  it  becomes  very  mild. 

The  period  of  incubation  of  smallpox  is  from  ten  to  four- 
teen days.  In  respect  to  the  definiteness  of  its  behavior  after 
infection  has  occurred,  it  is  unique  among  the  contagious 
diseases. 

The  onset  of  smallpox  is  abrupt,  the  initial  symptoms 
being-  nausea  and  vomiting',  with  chills  and  fever,  accom- 
panied by  severe  headache  and  backache,  the  latter  two  l)eing 
the  most  constant  symptoms.  The  prodromal  fever  is  very 
high  from  the  beginning",  often  reaching  104°  F.  (40°  C.) 
within  the  first  twenty-four  hours  after  the  onset.  The  actual 
smallpox  eruption  occurs  on  the  third  day  after  the  onset, 
although  prodromal  rashes,  erythematous  or  petechial,  are 
occasionally  noted  a  day  or  two  previously.  With  the  appear- 
ance of  the  rash  the  fever  subsides,  the  toxic  symptoms  abate, 
and  the  patient  feels  quite  well.  The  rash  is  at  first  macular, 
but  in  a  few  hours  these  macules  become  distinctly  raised  or 
papular.  Within  twenty-four  hours  after  the  appearance  of 
the  lesions  vesiculation  appears,  and  at  the  end  of  forty-eight 
hours  it  is  complete.  The  vesicular  stage  lasts  four  days, 
after  which  the  vesicles  become  pustules.  With  pustulation 
the  secondary  fever  begins,  and  continues  until  the  pustular 
stage  is  over.  On  the  ninth  or  tenth  day  of  the  eruption  the 
pustules  are  fully  developed  and  begin  to  break,  discharging 
a  foul,  purulent  material.  Thus  scabs  are  formed.  These 
usually  begin  to  separate  about  the  fourteenth  day  of  the 
eruption.  In  the  milder  cases  the  entire  process  will  be  com- 
plete within  three  weeks.  In  severe  or  confluent  cases  it  may 
be  a  matter  of  many  weeks  or  months.  Each  lesion  finally 
leaves  more  or  less  of  a  pit  or  pock-mark  in  the  skin. 

The  complications  of  smallpox  most  commonly  met  with 
are  laryngitis,  due  to  the  presence  of  the  lesions  on  the 
mucous  membranes,  bronchitis,  and  occasionally  broncho- 
pneumonia. Frequent  local  complications  are  the  formations 
of  superficial  abscesses  and  boils.  Orchitis  mav  occur,  and 
this  is  a  most  severe  complication.  Eye  complications,  such 
as  conjunctivitis,  keratitis,  and  even  panophthalmitis,  may 
occur.     Otitis  media  and  adenitis  are  occasionally  met  with. 


158  EXANTHEMATA. 

The  diagnosis  of  smallpox  is  not  difficult  in  a  classic  case. 
During  the  prodromal  stage  it  must  be  differentiated  from 
influenza  and  lumbago,  and,  when  prodromal  rashes  appear, 
from  scarlatina  and  measles. 

In  the  stage  of  eruption  the  disease  may  be  mistaken  for 
measles,  chicken-pox,  syphilis,  and  certain  drug  rashes. 

TREATMENT. 

The  treatment  of  smallpox  is  entirely  symptomatic.  In 
the  early  stages,  the  pain  in  the  back  and  headache  must  be 
relieved,  and  for  this  relief  an  opiate  may  be  required.  Dur- 
ing the  whole  course  of  the  disease  the  patient  should  be 
treated  as  any  other  fever  case.  It  is  the  practice  of  some 
who  have  had  considerable  experience  in  this  disease  to  allow 
somewhat  liberal  a  diet  in  the  period  between  the  primary 
and  secondary  fever.  This  is  not  necessary,  but  does  not 
appear  to  be  harmful.  The  liquid  diet,  principally  milk, 
should  be  plentiful  and  continued  while  the  fever  lasts,  and 
subsequently  it  may  be  gradually  increased. 

Elimination  must  be  aided,  the  bowels  kept  open,  and 
possible  interferences  with  kidney  function  forestalled  by  the 
use  of  large  quantities  of  water,  and,  perhaps,  potassium 
citrate  in  doses  of  15  to  30  grains  (1  to  2  Gms.)  every  fourth 
hour. 

There  is  no  drug  which  either  aborts  or  alters  the  attack. 
It  should  be  noted  that  vaccination  performed  immediately 
after  exposure  either  prevents  or  lessens  the  severity  of  the 
disease.  If  the  evidences  of  toxemia  be  severe,  stimulants 
may  be  needed,  such  as  alcohol  or  strychnin. 

Various  measures  have  been  advised  to  prevent  pitting  of 
the  lesions,  but  none  has  been  effectual.  Neither  light  nor 
darkness,  or  any  local  application  seems  to  have  any  effect. 
A  carbolized  vaselin  or  boric  ointment  dressing  will  allay 
irritation  and  help  the  loosening  of  scabs. 

Attention  to  the  eyes  is  essential.  The  use  of  a  boric  acid 
lotion  and  the  cleansing  of  the  lids  are  most  important. 
Headache  is  best  treated  by  the  use  of  the  ice-bag.  The 
coal-tar  products  might,  with  advantage,  be  used  in  certain 
cases. 


SMALLPOX.  159 

In  cases  of  severe  backache  hot  applications  may  bring 
relief.  Insomnia  and  delirium  are  oftentimes  a  troublesome 
factor  in  the  treatment,  and  are  best  controlled  by  bromids 
and  chloral  or  veronal. 

Every  case  of  smallpox  should  be  g'iven  as  complete  and 
prompt  isolation  as  possible,  and  to  accomplish  this  the  patient 
should  be  sent  at  the  earliest  possible  moment  to  an  isolation 
hospital.  Because  of  the  fact  that  the  disease  can  be  conveyed 
through  the  air,  the  hospital  should  be  situated  as  far  as  is 
practicable  in  a  sparsely  settled  or  uninhabited  locality.  It  is 
a  well-known  fact  that  in  certain  instances  smallpox  hospitals 
have  apparently  formed  foci  of  this  disease.  The  most  rigid 
quarantine  must,  then,  be  instituted  and  maintained. 

All  contacts  should  be  vaccinated  as  quickly  as  possible, 
and  thereafter  kept  under  close  observation  until  safely  past 
the  incubation  period.  Actual  quarantine  will  be  called  for  in 
instances  where  evidences  of  a  successful  and  recent  vaccina- 
tion are  lacking.  The  successful  vaccination  or  re-vaccination 
of  .contacts,  if  done  within  the  first  three  days  after  exposure, 
will  usually  prevent  altogether  an  attack  of  smallpox;  if  the 
operation  be  done  even  as  late  as  the  sixth  day  after  exposure 
it  will  modify  an  attack. 

The  movements  of  the  patient  for  two  weeks  prior  to  the 
time  of  falling  ill  should  be  carefully  investigated,  with  the 
idea  of  ascertaining  if  possible  any  connection  with  previous 
cases  yet  unreported.  Similar  efforts  should  be  put  forth  with 
regard  to  all  those  with  whom  the  patient  has  come  in  contact 
since  falling  ill,  in  order  to  discover  any  new  cases  and  thus 
prevent  new  foci  of  infection. 

The  danger  of  a  smallpox  epidemic  growing  out  of  any 
particular  outbreak  will  be  in  direct  proportion  to  the  percent- 
age of  unvaccinated  individuals  in  that  community. 

All  articles  of  negligible  value  that  have  been  in  contact 
with  the  patient  should  be  destro3^ed ;  all  articles  worth  saving 
should  be  disinfected.  The  thorough  fumigation,  cleaning, 
and,  as  far  as  possible,  refurnishing-  of  the  patient's  home  or 
apartments  should  always  be  done. 

The  patient  should  be  considered  fit  for  discharge  when  the 
last  scab  has  separated  from  the  skin,  and  when  all  cores  have 
been  removed  from  the  hands  and  feet. 


160  EXANTHEMATA. 

VARIOLOID. 

Varioloid  is  true  smallpox  in  modified  form,  and  is  the 
name  given  to  all  very  light  or  abortive  cases.  By  some 
authorities  the  term  is  restricted  to  include  only  those  cases 
in  which  the  modification  has  been  brought  about  by  a  more 
or  less  remote  vaccination. 

The  course  of  varioloid  is  shorter  and  milder  than  that  of 
the  other  forms  of  variola.  The  symptoms  are  often  very  diffi- 
cult to  recognize  because  of  their  mildness  or  aberrancy,  and 
sometimes  the  condition  is  never  suspected  until  secondary 
cases  arise.  The  prodromal  symptoms  may  be  exceedingly 
severe  and  the  rash  very  profuse.  In  every  instance,  however, 
the  course  of  the  disease  is  short,  the  eruption  aborting  in  the 
vesicular  stage  and  never  going  on  to  pustulation.  There  is 
no  secondary  rise  of  temperature,  and  the  attack  ends  with 
the  drying  of  the  vesicles. 

The  treatment  of  varioloid  is  the  same  as  for  any  of  the 
other  forms — purely  symptomatic.  Care  should  be  taken, 
however,  not  to  modify  the  quarantine.  These  cases  are 
capable  of  giving  rise  in  other  individuals  to  any  of  the  other 
forms  of  variola,  even  the  confluent  or  hemorrhagic  types. 

VACCINATION. 

Vaccination  is  the  production  of  a  localized  vaccinia  or 
cowpox.  It  is  accompanied  by  certain  febrile  manifestations 
and  other  evidences  of  systemic  infection. 

A  successful  vaccination  will  prevent  smallpox  for  a  period 
of  time  not  the  same  in  all  individuals.  It  varies  from  several 
years  to  a  whole  lifetime.  For  the  first  six  years  the  immunity 
will  be  absolute  in  every  instance.  For  longer  periods  of  time 
it  will  cause  a  supervening  smallpox  to  be  more  or  less  mild, 
the  so-called  varioloid  (q-v.). 

Technic  of  Vaccination.  The  part  selected  for  the  operation 
usually  is  the  outer  surface  of  the  left  arm,  just  below  the 
insertion  of  the  deltoid  muscle ;  in  females  the  leg  below 
the  knee  is  the  site  preferred.  After  thorough  cleansing 
with  soap  and  water,  and  the  subsequent  wiping  oif  with  alco- 
hol the  part  is  allowed  to  dry.    Scarification  is  then  done  with 


VACCINATION.  161 

a  blunt  lancet,  needle,  or  one  of  the  many  instruments  espe- 
cially devised  for  this  purpose.  Three  or  4  parallel  abrasions 
•%tj  in.  long'  should  be  made,  penetrating'  the  skin  just  deeply 
enough  to  show  serum,  but  not  to  cause  bleeding.  The  inocu- 
lation should  then  be  made  by  dropping  the  virus  on  the 
■wound  and  rubbing  it  in  cautiously  so  as  not  to  cause  further 
flo'vv  of  serum  or  blood.  A  temporary  shield,  easily  made  from 
a  small  piece  of  stiff  paper  and  adhesive  plaster,  should  be  ap- 
plied, w^ith  instructions  for  its  removal  the  following  morning. 
The  shield  is  used  for  no  other  purpose  than  that  of  prevent- 
ing infection  or  the  rubbing-  off  of  the  virus  by  the  clothing. 
Its  use  otherwise  might  prove  a  detriment.  The  only  local 
treatment  that  will  be  required  after  this,  except  in  the  event 
of  secondary  infection,  will  be  the  painting  of  the  site  twice 
daily  with  a  solution  of  iodin  1  part,  picric  acid  4  parts,  and 
alcohol  95  parts.  This  should  be  commenced  two  days  after 
operation.  Not  only  will  it  lessen  the  chances  for  outside  in- 
fection, but  it  will  also  cut  short  the  acute  stage  of  the  process. 

If  the  vaccination  is  successful,  or  "takes,"  a  small  papule 
surrounded  by  a  reddened  area  will  show  itself  in  from  three 
to  six  days.  In  a  few  days  more  vesicles  will  form  with  a  cen- 
tral depression  and  surrounded  by  a  reddened  and  indurated 
area.  The  vesicles  increase  in  size  for  several  days,  and  then 
dry  or  break,  leaving  a  quite  adherent  scab,  which  separates 
after  a  few  weeks  more.  The  scar  at  first  is  pink;  later  it  be- 
comes white,  with  numerous  small  pittings. 

Constitutional  symptoms  are  present  in  the  majority  of 
cases.  They  are  malaise,  anorexia,  headache,  and  fever.  Rest- 
lessness and  gastro-intestinal  disturbances  are  often  noted  in 
smaller  children.  Very  severe  symptoms  should  always  bring 
to  mind  a  possibility  of  secondary  infection. 

Vaccination  should  never  be  looked  upon  lightly  by  the 
physician.  The  strictest  asepsis  is  called  for  at  all  times  on  the 
part  of  doctor,  patient,  virus,  instruments,  and  dressings. 

Vaccination  is  one  of  the  greatest  blessings  given  to 
humankind  by  the  medical  profession ;  nothing  by  the  profes- 
sion should  be  done  to  discredit  it. 

In  the  face  of  an  exposure  to  smallpox,  or  even  in  the  midst 
of  an  epidemic,  there  are  no  contraindications  to  vaccination. 
In  the  interest  of  public  health,  if  for  no  other  reason,  the 

11 


162  EXANTHEMATA. 

physician  should  practise  at  every  opportunity  vaccination  and 
re-vaccination.  Were  this  possible  with  all  peoples,  smallpox 
w^ould  disappear  from  the  face  of  the  earth. 

The  Complications  of  Vaccination.  A  successful  vaccina- 
tion, properly  carried  out  with  due  regard  to  asepsis,  and  with 
proper  lymph,  never  offers  complications.  The  severity  of  the 
local  and  systemic  reactions  varies,  but  neither  requires 
treatment. 

All  the  possible  complications  of  vaccination  are  caused  by 
secondary  infections — either  at  the  time  of  vaccination  by  con- 
taminated lymph,  by  failure  in  asepsis,  or  by  subsequent  con- 
tamination of  the  wound. 

At  the  present  time,  due  to  care  in  manufacture,  there  is  no 
contaminated  lymph. 

A  failure  to  observe  strict  asepsis  at  the  time  of  vaccination 
may  lead  to  the  development  of  any  of  the  secondary  condi- 
tions, such  as  are  commonly  found  in  ordinary  wound  infec- 
tions. The  same  holds  true  of  infections  subsequent  to  the 
vaccination,  when  scratching-  with  dirty  fingers  is  a  common 
cause  of  complications. 

Tetanus  has  resulted  after  vaccination,  as  has  also  syphilis, 
but  these  are  rarities.  Erysipelas  and  cellulitis  are  more  com- 
mon. Perhaps  the  most  common  and  troublesome  result  of 
the  ordinary  infections  of  vaccination  is  the  delayed  healing  of 
the  site  of  the  pustule,  a  discharging  area  often  persisting  for 
weeks  or  months. 

The  treatment  of  the  complications  of  vaccination  is 
exactly  the  same  as  when  they  occur  after  other  abrasions  or 
surface  wounds. 

VARICELLA. 

Varicella,  or  chicken-pox,  is  a  highly  infectious  disease  of 
moderate  intensity,  and  characterized  by  fever  and  by  a 
specific  eruption. 

That  varicella  is  a  disease  separate  and  distinct  from 
variola  is  now  universally  admitted.  Controversy  regarding 
its  identity  with  variola,  however,  raged  throughout  the  med- 
ical world  for  several  generations,  as  late  even  as  1870-73, 
during  the  great  epidemic  of  those  years. 


VARICELLA.  163 

It  attacks  individuals  of  any  age,  although  it  is  encoun- 
tered chiefly  in  children,  especially  in  those  under  the  age  of 
ten.  It  is  my  experience  that  adults  are  more  infrequently 
the  subject  of  this  disease  than  of  any  other  of  the  acute 
exanthemata. 

It  is  most  highly  infectious ;  in  fact,  next  to  variola,  it  is 
the  most  infectious  of  all  these  diseases.  In  studying  out- 
breaks of  this  disease  in  the  wards  of  diphtheria  and  scarlet 
fever  hospitals,  it  is  my  experience  that  in  almost  every 
instance  secondary  cases  will  develop.  I  cannot  say  the  same 
of  other  diseases,  not  even  of  measles.  It  is  also  the  one  dis- 
ease which,  in  spite  of  the  most  painstaking  precautions,  will 
go  from  ward  to  ward,  and  from  building  to  building  even. 
This  forces  the  conclusion  that  it  is  spread  by  ways  other 
than  direct  contact.  I  feel  safe  in  saying  that  the  air,  third 
parties,  or  inanimate  objects  may  be  means  of  disseminating 
this  disease. 

Varicella  is  endemic  in  cities  and  the  larger  towns,  but  it 
does  not  take  on  the  form  of  large  epidemics,  as  is  the  case 
with  variola.  The  specific  micro-organism  is  supposed  to 
reside  in  the  local  lesion.  The  virus  is  rather  short-lived, 
being  in  this  respect  markedly  different  from  the  virus  of 
variola. 

Varicella  is  a  disease  of  the  colder  months,  beginning,  as 
a  rule,  in  middle  autumn,  and  lasting  into  the  late  spring  or 
early  summer. 

The  symptoms  of  varicella  are,  as  a  rule,  fever  and  a  rash. 
In  private  practice  the  rash  in  most  all  instances  is  the  first 
symptom.  In  institutions,  however,  where  closer  observation 
is  possible,  it  often  happens  that  a  moderate  fever,  99°  to  101° 
F.  (37.2°  to  38.3°  C.)  precedes  the  rash  by  a  few  hours. 

The  eruption,  if  seen  within  the  first  few  hours  after  its 
appearance,  consists  of  small  papules  which  disappear  on 
pressure.  These  develop  almost  at  once  into  vesicles.  The 
lesions  vary  greatly  as  to  number ;  in  some  cases  there  may 
be  so  few  as  half  a  dozen ;  in  other  instances  the  lesions  may 
number  several  hundred.  The  fever  may  go  as  high  as  104° 
F.  (40°  C). 

Complications  are  ver}^  few.  Secondary  infections,  through 
the   local   lesions,   are   the    only   ones   that   I    have    observed. 


164  EXANTHEMATA. 

Severe  conditions  mentioned  by  some  authors  as  complica- 
tions I  feel  sure  are  mere  coincidences. 

Recovery  is  the  unvarying  rule  in  all  uncomplicated  cases. 
All  fatalities  that  have  come  under  my  observation  I  have 
been  able  to  ascribe  to  some  cause  other  than  varicella.  The 
g-angrenous  type  of  the  disease,  w^hich  is  the  fatal  form,  is 
uncommon,  and  is  seen  in  children  already  the  subjects  of 
some  extremely  debilitating  condition  when  attacked,  such  as 
scarlet  fever,  diphtheria  or  tuberculosis. 

In  typical  cases  the  diagnosis  is  extremely  easy.  In  cer- 
tain borderline  cases,  however,  particularly  in  adults,  it  is 
impossible  to  differentiate  with  absolute  certainty.  The  only 
condition  of  importance,  with  which  such  cases  may  be  con- 
fused, is  variola,  especially  the  milder  form,  or  those  varieties 
modified  by  more  or  less  remote  vaccination.  As  is  the  case 
with  German  measles,  it  is  absolutely  imperative  that  the 
utmost  care  be  taken  in  every  instance  to  arrive  at  a  positive 
and  a  safe  diagnosis.  Failure  to  do  so  may  result  in  disaster 
to  the  community  in  a  public  health  and  business  way,  and 
also  may  impair  irretrievably  the  usefulness  of  the  family 
doctor  in  that  particular  community. 

A  scarlatinaform  prodromal  rash  is  encountered  occasion- 
ally with  varicella.  A  reasonable  amount  of  effort  should 
suffice  to  make  a  differentiation  from  scarlet  fever  possible 
in  all  cases. 

In  differentiating  these  diseases  the  following  factors 
should  be  studied  most  carefully: 

1.  The  movements  of  the  patient  for  at  least  two  weeks 
prior  to  the  appearance  of  the  rash,  in  an  effort  to  establish 
connection  between  patient  and  some  previous  case. 

2.  The  prodromal  symptoms. 

3.  The  character  of  the  lesions,  their  distribution,  and  the 
history  of  their  development. 

4.  History  and  evidences  of  vaccination,  bearing  in  mind 
the  influence  a  successful  vaccination  will  exert  in  modifying 
variola,  or  in  preventing  it  even,  especially  if  the  vaccination 
be  so  recently  done  as  within  the  previous  half  dozen  years. 


SCARLET    FEVER.  165 

TREATMENT. 

Next  to  German  measles  there  is  none  of  the  acute  exan- 
themata that  requires  so  little  treatment,  which  is  purely 
symptomatic.  Rest  in  bed  during  the  febrile  stage,  and  until 
the  lesions  are  well  past  the  acute  stage,  should  be  insisted 
upon  in  all  cases.  A  light  diet  and  some  mild  fever  mixture 
should  be  prescribed  if  the  fever  be  high.  To  prevent  sec- 
ondary infection,  which  constitutes  the  only  real  menace  of 
the  disease,  it  is  necessary  that  the  hands  be  kept  clean,  and 
that  they  be  securely  tied  in  well  padded  mittens  or  stockings. 
It  may  be  necessary  to  restrain  even  the  hands,  arms  or  legs. 
Itching  should  be  treated  with  tepid  baths,  or  by  sponging 
with  alcohol  well  diluted  with  water,  or  with  vinegar-water, 
1  part  to  3  parts.  After  that  any  bland  dusting  powder 
should  be  employed.  A  good  one  is :  Mentholis,  1  dram 
(4  Gm.)  ;  zinci  oxidi,  1  dram  (4  Gm.)  ;  pulv.  amyli,  1 
ounce  {32  Gm.);  talci,  1  ounce  (32  Gm.).  Secondary  infec- 
tions call  for  the  same  treatment  as  would  any  other  similar 
surgical  condition. 

The  patient  should  be  considered  ready  for  discharge  when 
separation  of  the  scabs  is  complete.  In  the  average  case,  free 
from  secondary  infection,  three  weeks  time  will  be  required. 

SCARLET    FEVER. 

Scarlet  fever  is  an  acute,  contagious,  self-limited  disease, 
characterized  by  a  diffuse  scarlet  eruption  and  a  pharyngeal 
inflammation. 

Susceptibility  varies  with  age  and  with  various  other  fac- 
tors. Immunity  is  usually  conferred  by  one  attack.  Children 
are  far  more  susceptible  than  adults,  but  even  all  children 
apparently  are  not  susceptible.  A  basis  upon  which  such 
comparative  or  absolute  immunity  may  be  explained  has  not 
been  found. 

The  etiology  of  scarlet  fever  is  obscure.  Its  contagious- 
ness, its  acute  febrile  character,  and  its  septic  complications 
all  point  to  the  belief  that  it  is  of  bacterial  origin,  but  a 
specific  organism  has  not  as  yet  been  demonstrated. 

In  most  cases  the  mode  of  contagion  is  undoubtedly  by 
direct   contact.      The    disease    may,    however,    be    spread   by 


166  EXANTHEMATA. 

intermediate  carriers,  either  persons  or  inanimate  objects, 
such  as  clothing,  carpets,  books  and  toys.  The  possibility 
of  the  transmission  of  the  infecting  agent  by  insects  is  to  be 
borne  in  mind  when  considering  quarantine  and  prophylaxis. 
The  disease  is  contagious  in  all  of  its  stages ;  most  highly  so 
when  it  is  most  active.  The  infecting  agent  resides  in  the 
secretions,  and  of  the  greatest  importance  in  this  connection 
are  the  oral  and  nasal  secretions  and,  in  complicated  cases, 
the  discharges  from  the  ears.  The  desquamating  particles  of 
skin,  unless  contaminated  by  secretions,  are  not  contagious. 

The  period  of  incubation  of  scarlatina  varies  from  one  to 
eight  dayS;  it  is  usually  from  two  to  five  days. 

The  onset  of  scarlet  fever  varies  to  a  great  extent  with  the 
severity  of  the  attack.  The  invasion  is  abrupt,  with  rapidly 
rising  temperature  from  101°  to  104°  F.  (38.3°  to  40°  C). 
Children  often  vomit  and  show  signs  of  general  depression. 
Sore  throat  will  be  complained  of  in  almost  every  instance, 
the  pharynx  and  tonsils  show  congestion,  and  very  early  in 
severe  cases  a  pseudomembrane  appears.  The  tongue  at  first 
is  covered  with  a  white,  furry  coating,  through  which  the 
swollen,  red  papillae  may  be  seen  to  project,  and  within  a  day 
or  two  the  tongue  begins  to  shed  its  coating,  and  by  the 
fourth  day  will  be  clean,  red  and  glistening,  with  the  papillse 
distinctly  prominent, — the  "strawberry  tongue"  of  scarlet 
fever.  The  consistency  with  which  the  tongue  thus  desqua- 
mates in  scarlet  fever  is,  in  certain  cases,  one  of  our  most 
important  diagnostic  aids. 

Usually  within  the  first  twenty-four  hours  after  onset  the 
rash  appears,  beginning  on  the  neck  and  upper  chest  and 
spreading  rapidly  over  the  entire  body.  It  is  a  distinctly 
punctiform  erythema,  and  in  typical  cases  varies  in  tint  from 
a  light  pink  to  a  light  or  dark  red  in  color.  It  may  be  so 
slight  as  to  be  barely  visible.  In  atypical  cases  it  may  assume 
a  macular  or  papular  appearance,  simulating  very  much  that 
of  measles.  Especially  is  this  so  about  the  wrists,  ankles  and 
the  dorsa  of  the  hands  and  feet.  It  is  sometimes  petechial, 
and  miliaria  as  minute  white  vesicles  are  often  seen.  The 
rash  may  be  limited  in  extent,  bei'ig  confined  to  the  chest, 
abdomen,  groins,  axillae,  or  the  bends  of  the  elbows.  It  may 
be  entirely  absent  in  very  mild  cases. 


SCARLET    FEVER.  167 

The  diag-nosis  of  scarlet  fever  depends  upon  the  peculiari- 
ties of  the  rash  and  the  pharyngeal  lesions.  Variations  in 
the  rash  make  a  correct  early  diagnosis  at  times  impossible. 
Indeed,  in  very  rare  instances  an  undoubted  scarlet-fever 
infection,  as  evidenced  by  the  incidence,  course  and  pharyn- 
geal symptoms,  has  been  recognized  in  the  absence  of  a  rash 
at  any  time  during  the  course  of  the  disease.  The  throat 
condition  may  be  such  that  a  dififerentiation  between  scarlet 
fever  and  diphtheria  will  be  impossible  on  the  clinical  evi- 
dence alone.  In  such  cases  it  is  only  after  repeated  bac- 
teriologic  examinations  that  a  positive  diagnosis  can  be  made. 
The  possibility  of  a  double  infection  of  scarlet  fever  and 
diphtheria  should  be  borne  in  mind.  The  greatest  problem 
in  the  differential  diagnosis  of  scarlet  fever  is  the  differentia- 
tion from  rubella.  The  characteristic  rash,  fever,  severe  onset, 
tongue  and  pharyngeal  symptoms  of  scarlet  fever,  and  their 
absence  in  rubella  generally  make  the  diagnosis  possible 
within  one  or  two  days.  Perhaps  the  most  difficult  problem 
in  the  diagnosis  of  scarlet  fever  is  the  recognition  of  the  very 
mild  cases.  Unless  we  encounter  them  in  an  institution  or 
during  an  epidemic  when  every  case  of  fever  in  a  child  is 
most  closely  examined,  it  is  very  easy  to  overlook  these  cases. 
Especially  is  this  true  where,  with  a  mild  febrile  course,  sore 
throat  is  not  complained  of.  In  a  cursoi-y  examination  a 
slight  rash  easily  could  be  overlooked,  and  if  it  fades  rapidly 
within  a  day  or  two  a  correct  diagnosis  would  be  impossible. 
Such  cases  are  particularl)^  important  because  if  proper  care 
is  not  taken  of  them  a  nephritis  is  likely  to  supervene ; 
moreover,  such  cases,  not  being  quarantined,  Avill  spread  the 
disease. 

The  clinical  course  of  the  disease  varies  with  its  severity. 
We  may  classify  cases  of  scarlet  fever  as:  (1)  Mild  cases, 
those  in  which  the  course  of  the  fever  is  from  100°  to  103° 
F.  {37.7°  to  39.4°  C),  the  pharyngeal  symptoms  not  very 
marked,  and  the  signs  of  general  infection  and  prostration 
slight.  In  these  cases  the  rash  fades  ver)'-  rapidly,  beginning 
on  the  third  or  fourth  day,  and  disappearing  entirely  by  the 
fifth  day.  (2)  Moderately  severe  cases.  In  these  the  onset  is 
marked  by  a  greater  severity.  The  temperature  goes  up  to 
104°  or  105°   F.,  (40°   or  40.5°   C),  the  rash  is  more  intense, 


168  EXANTHEMATA. 

and  does  not  begin  to  fade  until  the  fourth  or  the  sixth  day. 
The  throat  symptoms  are  more  marked,  and  an  exudation 
may  be  encountered.  The  systemic  manifestations  of  the 
disease  are  marked,  but  recovery,  apart  from  complications, 
is  the  rule.  (3)  Severe  cases,  those  with  a  sudden  onset  and 
a  rapidly  appearing,  widely  spread  and  intense  rash.  Ulcera- 
tion of  the  throat  is  common,  and  a  cervical  adenitis  always 
accompanies  it.  Rhinorrhea  is  marked.  The  fever  is  high, 
either  continuously  so  or  of  the  septic  type,  and  persists  for 
several  weeks.  The  symptoms  of  general  sepsis  are  marked, 
delirium  and  restlessness  the  rule,  and  the  pulse  is  rapid  and 
often  weak.  Gangrenous  changes  in  the  throat  may  be 
encountered.  In  the  fatal  cases  death  usually  takes  place 
from  sepsis  alone,  from  complications,  or  from  exhaustion. 
(4)  Malignant  cases,  those  in  which  death  occurs  from  an 
overwhelming  toxemia  within  a  short  time  after  the  onset  of 
the  disease.  These  cases  are  seen  only  in  the  courses  of 
severe  epidemics. 

The  pathologic  changes  in  scarlet  fever  may  be  described 
as  consisting  of  a  dermatitis  (erythema),  and  an  inflammation 
of  the  pharyngeal  structures  of  varying  degrees  of  intensity, 
with  a  lymphoid  enlargement  throughout  the  body  in  general. 

TREATMENT. 

The  treatment  of  scarlet  fever  comprises :  (a)  such  hand- 
ling of  the  case  that  the  spread  of  the  infection  is  minimized; 
{b)  the  symptomatic  and  general  treatment  of  the  disease 
itself;  and  (r)  the  anticipation  and  the  care  of  the  complica- 
tions. The  treatment  here  outlined  is,  of  course,  that  which 
is  possible  for  a  case  treated  at  home.  In  institutional  work 
the  problems  of  isolation  and  management  are  somewhat 
more  complex. 

Isolation.  Every  scarlet-fever  patient  should  be  isolated. 
Wherever  possible  the  patient  should  not  only  be  kept  alone 
in  a  room,  but  should  have  a  whole  floor,  preferably  the  upper 
floor,  or  the  one  most  distant  from  other  persons,  and,  if  pos- 
sible, one  with  a  door  opening  to  the  outside.  Separate  toilet 
facilities  are  desirable,  and  should  be  insisted  upon  whenever 
possible.  The  hanging  of  sheets  soaked  in  carbolic  acid  or 
in    bichlorid    of    mercury    solution    has    been    suggested    by 


SCARLET    FEVER.  169 

many,  but  this  precaution  is  not  necessary.  The  only  advan- 
tage of  such  a  procedure  is  that  it  serves  as  an  ocular 
reminder  that  a  quarantine  is  on,  and  should  be  respected. 
All  isolation  will  not  be  effective,  however,  if  the  attendants 
and  nurses  do  not  take  every  possible  precaution.  Those 
entering-  the  room  should  put  on  a  cap  and  gown  and  remove 
them  at  the  door  when  leaving.  Here  we  must  recall  the  fact 
that  the  infecting  agent  resides  in  the  secretions,  and  that  in 
their  transference  the  danger  lies.  Therefore,  upon  leaving 
the  patient's  room  the  careful  washing  of  the  face  and  hands 
and  the  brushing  of  the  shoes  are  positively  essential.  The 
patient  should  have  separate  dishes  and  eating  utensils.  Bet- 
ter than  serving  meals  on  dishes  to  be  brought  into  the  room 
is  the  practice  of  putting  the  food  into  special  ones  from  the 
patient's  apartment,  placed  just  outside  the  door,  care  being 
taken  not  to  touch  them.  Nothing  should  be  allowed  to  leave 
the  room  until  after  thorough  cleansing  and  sterilization. 
Especial  care  as  to  excreta,  soiled  dressings,  and  handkerchiefs 
is  imperative.  For  the  latter  pieces  of  gauze  should  be  used, 
and  burned  like  everything  else  of  negligible  value.  To  pre- 
vent the  carrying  of  infectious  material  by  insects,  the  room 
or  apartment  should  be  thoroughly  screened.  It  is  hardly 
necessary  to  mention  that  a  large,  airy,  well-ventilated  room 
is  to  be  preferred,  but  it  should  be  one  free  of  draughts. 
After  the  patient  has  recovered  and  is  ready  to  leave  the 
apartment,  provision  should  be  made  for  its  immediate  and 
thorough  cleansing  and  fumigation.  My  own  feeling  is  that 
a  painstaking  washing  of  the  walls,  floors,  furniture  and 
utensils  with  soap  and  water,  and  the  steaming  or  sunning 
of  mattresses  and  linen  will  be  all  that  is  required.  Where 
possible,  the  refinishing  of  the  walls,  floors  and  furniture  will 
add  to  the  feeling  of  security. 

Medical  and  Hygienic  Management.  A  diagnosis  of  scar- 
let fever  having  been  made  and  the  patient  isolated,  the  first 
thing  of  importance  is  to  put  the  patient  to  bed,  even  though 
the  attack  be  of  the  mildest  form.  It  is  too  common  an 
experience  to  see  children  upon  whom  the  rash  is  still  visible 
up  and  about  the  house.  The  patient  should  be  kept  in  bed 
for  at  least  four  weeks ;  especially  is  this  advisable  in  the 
smaller  children.     The  principal  reason  for  this  is  the  avoid- 


170  EXANTHEMATA. 

ance  of  draughts  and  changes  of  temperature,  thus  reducing 
to  a  minimum,  in  conjunction  with  our  other  care,  the 
patient's  liability  to  nephritis,  rhinitis,  and  other  complica- 
tions. The  temperature  of  the  room  is  of  vital  importance 
at  all  stages  of  the  disease.  I  have  found  that  the  severer 
acute  cases,  and  particularly  the  septic  ones  with  hyper- 
pyrexia, restlessness  and  delirium,  thrive  best  when  the  tem- 
perature is  maintained  at  between  55°  or  60°  F.  (12.7°  or 
15.5°  C).  The  milder  acute  cases,  as  well  as  the  convales- 
cents, do  well  in  a  temperature  of  68°  to  70°  F.  (20°  to  21.1° 
C).  When  the  patient  is  once  out  of  bed  he  may,  if  not  too 
weak,  be  allowed  out-of-doors  on  warm,  quiet,  sunny  days. 

The  isolation  of  the  patient  having  been  arrang'ed,  and  the 
length  of  the  stay  in  bed  having  been  thoroughly  impressed 
upon  the  family  and  attendants,  with  the  understanding  that 
it  is  to  be  absolute,  the  general  care  of  the  patient  must 
receive  our  next  attention.  Warm  bed-apparel  should  be  the 
unvarying  rule.  A  flannel  shirt  will  prevent  chilling  of  the 
shoulders  and  chest,  the  parts  least  protected  by  the  bed- 
coverings.  Careful  attention  to  the  skin  should  be  given  from 
the  very  first.  A  daily  sponge  or  bath  with  soap  and  tepid 
water  is  positively  called  for,  inasmuch  as  it  contributes  to 
bodily  comfort,  assists  in  elimination,  and  helps  restore  the 
skin  to  a  normal,  healthy  condition.  Inunctions  are  of  no 
value  as  a  routine  measure,  except  when  used  to  prevent  the 
scattering-  of  the  exfoliatingf  skin. 

Other  matters  of  importance  pertaining  to  the  general 
hygiene  of  the  patient  are  careful  attention  to  the  kidneys  and 
bowels.  The  menace  of  nephritis  always  should  be  kept  in 
mind.  The  daily  measuring  and  recording  of  the  urinary  out- 
put, and  the  chemical  analysis  every  second  day  are  abso- 
lutely imperative.  If  there  be  any  albumin,  a  trace  even,  a 
daily  analysis,  microscopic  and  chemic,  should  be  done  until 
the  analysis  is  normal  again. 

At  least  one  good  movement  of  the  bowels  should  be 
assured  every  day.  For  smaller  children  castor  oil,  or  pulvis 
glycyrrhiza  compound,  will  do  good ;  for  older  children  and 
adults  nothing  is  better  than  salines.  An  occasional  colonic 
irrigation,  say  twice  a  week  in  mild  or  convalescent  cases,  will 
do  much  by  keeping  clean  the  lower  bowel. 


SCARLET    FEVER.  1/1 

The  diet  in  scarlet  fever  always  should  receive  the  closest 
attention.  As  vomiting  in  most  cases  is  quite  persistent  dur- 
ing the  first  twenty-four  hours,  it  will  do  no  harm,  and  even 
be  helpful,  to  withhold  all  nourishment  during  that  period. 
Thereafter,  during  the  acute  stage,  a  pure  milk  diet  is  the 
ideal  one.  It  is  my  practice  to  have  the  patient  given  food 
at  three-hour  intervals;  as  much  milk  as  the  patient. may 
.desire.  The  patient,  however,  is  not  to  be  awakened  for  food 
or  medicine.  Meat-broths  are  not  desirable  if  milk  can  be 
taken.  In  addition  to  the  milk,  a  daily  feeding  of  some  fresh 
fruit  juice,  well  diluted  with  water,  should  be  given  one  hour 
before  the  regular  nourishment.  Water  should  be  given  freely 
at  regular  intervals,  and  between  at  the  patient's  request. 
There  is  no  objection  to  the  use  of  good  carbonated  waters, 
which  oftentimes  will  be  found  more  satisfying  to  adults  than 
plain  water. 

In  mild  cases  and  in  those  of  moderate  severity  no  difii- 
culty  will  be  encountered  in  maintaining  the  patient's  strength 
on  a  strict  milk  diet.  The  average  case  I  keep  on  milk  and 
fresh  fruit  juices  until  the  temperature  has  been  normal  for 
from  seven  to  ten  days.  Then,  if  the  kidneys  be  in  good 
condition,  secreting  a  normal  quantity  with  negative  findings, 
the  diet  may  be  increased  by  the  cautious  addition  of  strained 
oatmeal,  the  pulp  of  stewed  fruits,  toast,  bread  and  butter. 
and  puddings  of  a  simple  nature.  Weak  tea  and  coffee 
may  be  allowed  those  accustomed  to  their  use.  This  dietary- 
should  prove  sufficient  until  the  patient  is  safely  past  the 
fourth  week,  the  stage  of  the  disease  when  nephritis  is  most 
likely  to  show  itself.  After  this  various  vegetables,  fish,  and 
the  white  meat  of  chicken  may  be  permitted.  In  septic  cases 
or  those  in  which  the  fever  is  unusuall}^  protracted,  or  the 
patient  further  weakened  by  complications,  a  resort  to  a  diet 
other  than  milk  may  be  necessary  at  an  earlier  time  than  in 
ordinary  cases.  In  cases  of  persistent  vomiting  rectal  feed- 
ing may  be  necessary,  using  peptonized  milk,  beef-juice  and 
whisky  in  saline  solution.  Sore  throat  m'ay  be  of  such  a 
degree  as  to  render  swallowing  difficult  and  make  nasal  feed- 
ing necessary.  It  is  rarely,  however,  that  this  condition  can- 
not be  met  successfully  by  the  exercise  of  patience  or  tact  on 
the  part  of  the  parent  or  nurse. 


172  EXANTHEMATA. 

In  considering  the  medical  treatment  of  scarlet  fever  it 
must  be  remembered  that  the  exact  etiology  of  the  disease 
is  unknown,  and  that  specific  treatment  by  sera  or  vaccine  is 
out  of  the  question.  Nor  have  we  at  our  command  any  drug 
or  other  method  of  treatment  which  is  in  any  way  specific. 

There  are  two  cardinal  symptoms,  or  conditions,  which 
underlie  our  diagnosis  of  scarlet  fever,  the  rash  and  the 
angina.  The  rash  rarely  requires  treatment.  A  bright,  well7 
developed  rash  denotes  good  heart  action,  and  is  to  be  desired. 
Should  the  rash  be  scant  and  not  of  good  color,  the  use  of 
external  measures,  such  as  the  hot  pack  or  wrapping  the 
patient  in  blankets  with  hot-water  bottles,  is  called  for.  This 
is  true  even  when  the  temperature  is  high,  because  the  result- 
ing increase  of  skin  elimination  will  bring  with  it  a  drop  in 
temperature  and  make  the  patient  less  restless. 

The  sore  throat  of  scarlet  fever  needs  attention  entirely 
according  to  its  severity.  In  smaller  children  the  milder 
degrees  of  sore  throat  will  do  best  if  left  alone.  In  the  older 
ones,  those  able  to  gargle,  the  use  of  a  solution  of  normal 
saline  or  of  the  liquor  antisepticus  alkalinus  of  the  National 
Formulary  three  times  daily  is  desirable.  Local  treatment  of 
the  throat  by  irrigating,  syringing  or  swabbing  is  to  be  con- 
demned, except  under  certain  conditions.  Where  the  patient 
is  an  adult  or  a  child  sufficiently  tractable  to  co-operate, 
irrigations  of  normal  saline,  as  hot  as  can  be  borne  with  com- 
fort, may  be  allowed.  Again,  when  ulceration  occurs,  the 
gentle  cleansing  with  one-half  strength  hydrogen  peroxid  and 
the  subsequent  application  of  one-half  saturated  solution  of 
potassium  chlorate  to  the  afifected  parts  only  are  indicated. 
But  before  permitting  this  the  physician  should  be  sure  that 
the  nurse  in  charge  is  a  dependable  person,  who  thoroughly 
understands  that  gentleness  should  be  the  outstanding  fea- 
ture of  the  operation.  In  certain  prolonged  cases,  however, 
the  application  of  a  5  per  cent,  copper-sulphate  solution, 
instead  of  the  potassium  chlorate,  will  be  necessary,  but  these 
instances  will  be  rare.  Local  applications  should  be  made 
twice  daily. 

The  mildness  of  throat  symptoms  at  the  outset  should  not 
lead  us  to  neglect  the  daily  routine  examination  of  the  mouth. 
The  condition  of  the  throat  in  the  acute  stage  of  almost  every 


SCARLET   FEVER.  173 

case  is  a  fair  index  to  the  patient's  general  condition.  Fur- 
thermore, by  this  daily  inspection  various  forms  of  stomatitis, 
tonsillitis,  diphtheria,  and  the  Koplik  spots  of  measles  may  be 
recognized  early  and  promptly  treated. 

The  only  medicinal  remedy  that  I  use  as  a  routine  during 
the  febrile  stage  of  scarlet  fever  is  citrate  of  potassium,  given 
every  two  hours  in  full  doses  to  adults,  and  in  corresponding 
doses  to  children,  1  grain  to  every  year  of  age,  in  an  abund- 
ance of  water.  When  the  patient's  temperature  has  been 
normal  for  four  or  five  days  Basham's  mixture  is  substituted 
for  the  potassium  citrate.  As  a  roborant,  when  the  patient  is 
on  full  diet,  the  syrup  of  iodid  of  iron,  in  combination  with 
the  syrup  of  hypophosphites,  is  preferred. 

The  complications  of  scarlet  fever  call  for  prompt  and 
effective  treatment.  For  purposes  of  convenience  we  may 
divide  them  into  those  that  occur  during  the  stage  of  fever 
and  those  that  occur  during  convalescence. 

Early  Complications.  The  treatment  of  scarlatinal  sore 
throat  has  already  been  described  in  detail.  In  addition  to  a 
pharyngitis,  there  may  be  an  abscess,  either  a  true  quinsy  or 
a  retropharyngeal  abscess.  These  are  comparatively  rare, 
especially  the  latter.  Both  must  be  treated  in  the  usual  man- 
ner by  prompt  incision  and  ordinary  after-treatment. 

A  minor  complication  often  met  with  is  cracking  of  the 
lips,  and  for  the  relief  of  this  troublesome,  but  not  serious 
condition,  I  have  found  compresses  of  camphor-water  more 
efficacious  than  ointments.  Oftentimes  the  splinting  of  the 
child's  arms  will  be  necessary  to  prevent  picking,  and  thereby 
infecting  the  lips. 

Ulcers  of  the  aphthous  variety  are  sometimes  encountered 
on  the  tongue  of  cases  in  which  the  temperature,  for  unex- 
plained reasons,  has  failed  to  come  to  normal,  remaining 
around  100°  and  101°  F.  (37.7°  and  38.3°  C).  Potassium 
chlorate,  as  previously  mentioned  for  other  mouth  conditions, 
will  prove  a  specific  for  this  aphthous  stomatitis. 

The  nose  in  scarlet  fever  may  be  a  source  of  great  trouble, 
and  rhinorrhea  is  one  of  the  most  intractable  complications 
of  the  disease.  Its  existence  lengthens  the  infectious  period 
and  thereby  prolongs  quarantine.  Conservative  treatment,  as 
with  the  throat,  is  the  best.     To  prevent  the  formation  of 


174  EXANTHEMATA. 

crusts  and  thereby  to  facilitate  drainage  I  have  found  a  com- 
bination of  menthol,  2  grains  (0.13  Gm.)  ;  camphor,  3  grains 
(0.195  Gm.)  ;  eucalyptol,  1  fluidram  (3.75  mils),  and  liquid 
albolene  to  make  1  fluidounce  (30  mils),  to  be  of  advantage. 
Five  drops  of  this  should  be  instilled  into  each  nostril  three 
times  daily.  Argyrol  instillations  I  have  tried,  but  with  indif- 
ferent results. 

The  eye  complications  met  with  in  scarlet  fever  are  con- 
junctivitis, blepharitis  and  ulcerative  keratitis,  and  with  the 
exception  of  the  last  named,  they  are  rarely  serious.  They 
require  the  same  treatment  as  when  due  to  other  causes. 

Laryngeal  complications  of  scarlet  fever  are  infrequent, 
although  membranous  or  ulcerative  laryngitis  may  occur.  In 
some  instances  intubation  or  tracheotomy  may  be  required, 
and  it  will  be  impossible  to  differentiate  the  condition  from 
the  laryngitis  of  diphtheria,  except  by  repeated  culture  and 
careful  observation. 

In  the  milder  cases,  pyrexia  requires  no  treatment  other 
than  the  ice-bag  to  the  head.  In  the  severer  forms,  tepid 
sponges  every  three  or  four  hours  should  be  employed,  with 
a  colonic  irrigation  once  daily,  preferably  in  the  early  evening. 
If  delirium  and  restlessness  persist,  the  use  of  bromids  in 
doses  of  10  grains  (0.65  Gm.)  every  two  hours  for  a  child  10 
or  12  years  of  age  is  indicated,  and  will  usually  prove  suffi- 
cient. In  severe  cases  of  delirium,  chloral  hydrate  should  be 
given  in  combination  with  the  above,  5  grains  (0.325  Gm.) 
every  two  hours  for  three  or  four  doses.  Great  care  always 
should  be  exercised  in  giving  chloral,  and  I  recommend  it  only 
in  those  cases  in  which  the  restlessness  is  most  pronounced. 
Other  drugs  that  have  proven  efficient  at  times  are  veronal 
and  paraldehyd.     Opium  I  rarely  use  in  any  form. 

We  must  distinguish  between  the  early  febrile  albuminuria 
and  the  true  nephritis  of  scarlet  fever.  Simple  albuminuria 
occurs  earlier  in  the  course  of  the  onset,  and  disappears,  as  a 
rule,  with  the  fever.  An  early  true  nephritis,  however,  must 
be  reckoned  among  the  possibilities,  and  must  not  be  treated 
as  a  simple  albuminuria.  The  continuance  of  a  milk  diet  and 
the  use  of  potassium  citrate  with  water  given  freely  will,  as 
a  rule,  be  the  only  treatment  necessary  for  a  simple  febrile 
albuminuria. 


SCARLET    FEVER.  175 

« 

Arthritis  occurs  in  3  per  cent,  of  all  scarlet  fever  cases,  the 
joints  most  commonly  affected  being  those  of  the  wrist,  hand 
and  fingers.  The  larger  joints  are  occasionally,  but  very 
rarely,  arthritic ;  and  in  these  suppuration  may  occur,  although 
it  does  not  occur  in  the  smaller  joints.  The  treatment  is  the 
same  as  that  for  any  other  inflamed  joint  condition  of  a  non- 
surgical nature.  The  use  of  aspirin  or  the  salicylates  in  alka- 
line solution  will  be  sufficient  internal  medication.  The  joint 
affected  must  be  put  absolutely  at  rest  by  splints;  local  appli- 
cations, such  as  10  per  cent,  ichthyol  ointment  or  lead-water 
and  laudanum,  ma}^  be  employed.  Constant  moistening  of  the 
dressings  with  a  saturated  solution  of  magnesium  sulphate 
often  relieves  the  pain  and  inflammatory  symptoms. 

Ear  complications  in  scarlet  fever  are  not  only  at  times 
grave,  but  have  much  to  do  with  the  actual  duration  of  the 
infectious  period  of  a  given  case.  Acute  otitis  media  may 
occur  at  any  time  in  the  course  of  the  disease,  and,  therefore, 
a  careful  examination  of  the  drum-membrane  should  be  made 
a  part  of  the  routine.  It  commonly  occurs  in  cases  in  which 
there  has  been  marked  sore  throat  or  rhinorrhea,  but  it  may 
occur  with  the  mildest  of  cases  and  without  warning.  Often- 
times the  discharge  is  the  first  and  only  evidence.  As  soon 
as  any  symptoms  indicate  ear  trouble  a  thorough  examination 
should  be  made,  and,  if  the  drum-membrane  should  be  found 
red  or  bulging,  free  incision  is  called  for  at  once.  This  should 
be  done  in  the  lower  posterior  quadrant.  There  can  be  no 
doubt  that  by  temporizing  with  middle-ear  disease  we  invite 
graver  ear  complications,  such  as  chronic  otitis  media,  mas- 
toiditis, thrombosis  and  cerebral  a1)scess.  After  incision  of 
the  drum-membrane  the  relief  of  all  symptoms  is  immediate, 
and  further  local  treatment  is  rarely  necessary  during  the 
further  course  of  the  acute  stage.  External  cleansing  and 
keeping  the  canal  clear  to  maintain  free  drainage  are  all  that 
is  needed.  Routine  irrigations  I  do  not  advise.  However, 
should  local  treatment  at  any  further  time  be  indicated,  it 
should  be  done  by  the  doctor  only,  and  never  without  the  use 
of  a  head-mirror  and  speculum. 

Mastoiditis  may  supervene  upon  otitis  media.  With  the 
application  of  external  heat  and  extra  attention  to  the  procur- 
ing of  drainage  through  the  ear,  operation  may  be  avoided  in 


176  EXANTHEMATA. 

* 

some  instances.  Should  the  redness  and  tenderness  behind 
the  ear  become  marked  or  the  patient  show  signs  of  severe 
S3^stemic  disturbance,  and  especially  if  fluctuation  be  present, 
excision  of  the  mastoid  cells  should  be  done.  Rarely  is  fur- 
ther interference  justifiable  at  this  stage  of  the  disease. 
Should  the  condition  become  chronic,  radical  and  more  com- 
plete operation  may  be  done,  always  by  a  competent  surgeon, 
after  the  purely  scarlatinal  part  of  the  disease  has  spent  itself. 

Of  the  late  complications,  or  those  occurring  when  con- 
valescence should  be  well  under  way,  postscarlatinal  nephritis 
is  the  gravest  and  most  important.  Attention  already  has 
been  drawn  to  the  frequency  of  febrile  albuminuria  during 
scarlet  fever,  and  the  possibility  of  an  earty  nephritis. 

The  nephritis  of  scarlet  fever  is  characterized  especially 
by  changes  in  the  glomeruli,  although  the  pathologic  process 
affects  the  structures  of  the  kidneys  in  general.  The  occur- 
rence of  casts  or  a  diminution  in  the  daily  quantity  of  urine 
should  at  once  lead  to  very  active  measures  of  treatment. 
Edema  is  rarely  encountered  where  there  has  been  a  sys- 
tematic watching  of  the  daily  urinary  findings.  It  is  only  in 
the  neglected  cases  that  this  symptom  draws  the  physician's 
attention  to  the  underlying  nephritis.  Some  degree  of  neph- 
ritis is  found  in  about  10  per  cent,  of  all  cases  of  scarlet  fever. 
It  rarely  becomes  chronic. 

The  treatment  of  nephritis  following  scarlet  fever  must  be 
prompt  and  vigorous.  It  must  include:  (1)  Restriction  of 
the  diet  to  milk  and  the  administration  of  water  in  consider- 
able quantities.  Later  in  the  disease,  say  after  three  or  four 
weeks,  when  there  are  present  anemia  and  emaciation,  even 
though  albumin  may  persist  in  the  urine,  the  diet  may  be 
increased  to  advantage  by  the  addition  of  eggs,  cereals,  bread 
and  butter,  stewed  fruits  and  puddings.  (2)  Free  elimination 
by  the  bowels.  For  this  purpose  I  employ  niag"nesium  sul- 
phate or  pulv.  jalapse  comp.  for  adults  and  larger  children, 
and  oleum  ricini  for  children  4  years  old  and  under.  (3)  The 
use  of  diuretics.  Potassium  citrate  alone  or  with  sp.  setheris 
nitrosi  and  liq.  ammonii  acetatis  is  given  as  a  routine.  In  the 
later  stages  of  nephritis,  when  anemia  is  present,  Basham's 
mixture  is  substituted.  Other  diuretics  that  might  be  used 
are  caffein  and  diuretin.     (4)  The  hot  pack.    This  should  be 


SCARLET    FEVER.  177 

used  at  intervals  varying  in  frequency  from  once  daily  to 
every  four  hours,  and  should  be  continued  until  examinations 
show  the  urine  to  be  negative  on  four  successive  days.  After 
this  the  pack  should  be  withdrawn  gradually,  and  the  diet 
correspondingly  increased.  I  consider  the  hot  pack  as  our 
most  important  means  of  combating  nephritis,  inasmuch  as 
the  increased  skin  elimination  lifts  the  bulk  of  the  burden 
from  the  crippled  kidneys. 

Under  such  vigorous  treatment  uremia  should  not  super- 
vene. However,  if  this  should  develop,  purgation  with 
Ol.  tiglii  or  elaterium,  and  venesection  followed  by  salt 
solution  intravenously  should  be  the  measures  immediately 
adopted.  The  use  of  dry  cups  over  the  kidneys  and  hot  saline 
by  the  bowel  is  also  indicated.  Whether  poultices  do  any 
good  I  cannot  say  positively,  but  they  do  no  harm,  and  are, 
therefore,  used.  Oftentimes  their  use  brings  from  the  patient 
an  expression  of  comfort.  They  should  be  composed  of  flax- 
seed ar^d  powdered  digitalis-leaves,  4  parts  to  1,  or  flaxseed 
and  mustard,  16  parts  to  1.  They  should  be  large  enough  to 
cover  the  entire  lumbar  region  and  applied  warm. 

For  adenitis,  usually  of  the  cervical  variety,  the  best  treat- 
ment is  heat,  applied  as  hot  fomentations  or  by  means  of 
poultices.  Should  softening  occur,  free  incision  and  drainage 
are  indicated.  The  fear  on  the  part  of  some  that  heat  from 
poultices  favors  suppuration  in  the  adenitis  of  the  acute  stage 
of  the  disease  has  not  been  justified  by  my  experience.  Local 
medicinal  applications  I  have  not  found  of  advantage  in  short- 
ening an  attack  of  adenitis  or  in  preventing  suppuration.  The 
possibility  of  the  glandular  discharges  containing  the  infect- 
ing agent  of  scarlet  fever  and  the  individual  thereby  becom- 
ing a  carrier  should  always  be  borne  in  mind. 

Chest  complications  in  scarlet  fever  are  rare.  Those  aft'ect- 
ing  the  heart  are  endocarditis,  pericarditis  and  myocarditis. 
The  lung  complications  are  bronchitis,  bronchopneumonia, 
lobar  pneumonia,  pleurisy  and  emp3'ema.  The  treatment 
required  is  the  same  as  when  due  to  other  causes. 

Reinfections  or  relapses  in  scarlet  fever  occur  oftener  than 
is  generally  supposed.  By  a  relapse  we  mean  the  redevelop- 
ment of  the  disease  in  an  individual  before  complete  recovery 
from  the  first  attack.     Some  authorities  state  that  the  severity 

12 


178  EXANTHEMATA. 

of  a  relapse  is  in  inverse  proportion  to  that  of  the  first  attack. 
They  usually  occur  about  the  middle  of  the  fourth  week. 
The  symptoms  are  like  those  of  the  first  attack,  vomiting, 
sore  throat,  fever  and  a  rash,  followed  by  desquamation.  As 
a  rule,  relapses  are  mild  and  end  in  recovery.  The  treatment 
is  the  same  as  for  the  initial  attack. 

Second  attacks  of  scarlet  fever,  those  occurring  after  full 
recovery,  may  occur  also,  the  period  of  time  between  the 
attacks  varying  from  six  weeks  to  several  years. 

Scarlet  fever  seems  to  prepare  a  fertile  field  for  the  develop- 
ment of  other  infectious  diseases,  especially  for  diphtheria, 
measles  and  varicella.  The  daily  routine  of  inspecting  the 
throat,  as  a  means  of  early  recognition  and  prompt  treatment, 
has  been  mentioned  as  a  necessary  procedure  in  all  cases  of 
scarlet  fever.  In  the  severe  anginose  cases  of  scarlet  fever, 
even  where  the  chances  of  diphtheria  being  present  as  a  coin- 
cident infection  are  not  very  strong,  the  giving  of  a  curative 
dose  of  diphtheria  antitoxin  is  indicated.     It  can  do  no  harm. 

Other  conditions  that  may  complicate  scarlet  fever,  though 
rarely,  are  meningitis,  jaundice,  peritonitis,  eczema,  vaginitis 
and  postfebrile  mania.     They  require  no  special  treatment. 

And  lastly,  there  must  be  included  in  the  treatment  of 
scarlet  fever  the  determination  of  the  time  when  the  patient 
is  fit  for  release  from  quarantine ;  when,  as  near  as  we  can 
judge,  he  ceases  to  possess  the  power  to  infect.  Because  of 
its  bearing  upon  the  general  public  health  there  is  nothing 
which  calls  for  greater  care  than  this  decision.  There  are  no 
certain  means  by  which  we  can  arrive  at  such  a  conclusion. 
"Return  cases"  occur  in  about  2  per  cent,  of  all  discharges 
from  hospitals,  according  to  statistics.  My  own  methods  in 
this  matter,  based  upon  experience  only,  approximately  are 
as  follows : 

All  adults  and  larger  children,  never  the  subject  of  com- 
plications, may  be  discharged  at  any  time  after  a  detention 
of  thirty-five  days  dating  from  onset  of  the  illness. 

Mild  cases  in  smaller  children,  not  the  subjects  of  compli- 
cations, will  require  a  minimum  detention  period  of  forty-two 
days. 

Cases  with  rhinorrhea  should  be  detained  three  months, 
and  in  every  instance  should  be  cultured  for  diphtheria  bacilli. 


MEASLES.  179 

Otorrhea  calls  for  detention  of  from  three  to  four  months. 
"A  running-  ear"  should  be  kept  for  four  months ;  a  moist  ear, 
in  which  but  a  few  drops  show  every  day  or  so,  may  be 
released  in  three  months. 

Cases  with  acutely  inflamed  glands  should  not  be  dis- 
charged until  all  signs  of  inflammation  shall  have  disappeared. 
Suppurating  glands  must  have  healed  perfectly  before  the 
release  of  the  patient  is  permitted. 

Desquamation  in  itself  probably  does  no  harm  in  any 
stage  of  the  disease,  and  certainly  none  after  the  end  of  the 
fourth  week.  Because,  however,  of  the  universal  belief  in 
the  infectiousness  of  the  scales  of  the  skin,  it  is  my  custom 
to  see  that  all  cases  are  free  from  them  before  being  released. 
In  most  all  cases  desquamation  is  complete  before  the  end  of 
the  sixth  week. 

At  the  time  of  the  patient's  discharge  he  should  be  given 
a  thorough  and  vigorous  cleansing  bath  of  soap  and  water. 
This  should  include  the  scrubbing  of  the  head  and  the  cleans- 
ing of  the  nose  and  the  ears.  The  mouth  should  be  made 
clean  with  a  mild  antiseptic  gargle,  after  attention  to  teeth 
and  gums  by  a  dental  surgeon. 

The  apartments  occupied  by  the  patient  should  be  cleaned 
and  fumigated  in  the  manner  already  mentioned. .  (See  p.  169.) 

And  finally,  in  spite  of  the  most  careful  observation  of  the 
patient  from  the  beginning  of  illness  to  the  end  of  quarantine, 
and  in  spite  of  the  most  painstaking  attention  to  everything 
connected  with  the  treatment,  the  greatest  danger  of  spread- 
ing the  disease  will  be  the  patient  himself. 

MEASLES. 

Measles  is  an  acute  contagious  disease  characterized  by  a 
peculiar  eruption  and  a  catarrhal  condition  of  the  upper  air- 
passages  and  bronchi. 

The  etiology  of  measles  is  unknown.  It  partakes  of  all 
the  characteristics  of  a  disease  caused  by  a  micro-organism, 
but  the  specific  causative  factor  has  not  been  isolated. 

The  mode  of  transference  of  the  disease  is  doubtless  most 
often  by  direct  contact.  The  most  infectious  period  of  the 
disease  is  the  early  one,  when  the  discharges  from  the  nose 


180  EXANTHEMATA. 

and  eyes  are  most  marked,  and  before  or  just  when  the  rasli 
is  beginning  to  appear.  It  may  be  possible  that  the  disease 
could  be  carried  by  a  third  person  or  object  by  the  transfer- 
ence of  small  particles  of  infectious  material,  but  this  is,  I 
think,  quite  rare,  owing  to  the  fact  that  the  virus  is  very 
vulnerable  and  short-lived.  Apparently  measles  is  not  spread 
by  water  or  by  food,  nor,  contrary  to  the  old  belief,  are  the 
desquamating  particles  of  the  skin  infectious. 

Measles  may  occur  at  all  ages  of  life,  but  under  ordinary 
conditions  it  is  essentially  a  disease  of  childhood.  It  is  prob- 
ably the  most  widely  disseminated  of  all  the  infectious  dis- 
eases, and  in  epidemics  attacks  persons  of  all  ages  who  are 
not  immune  because  of  a  previous  attack.  Immunity  is  con- 
ferred by  a  previous  attack  in  almost  all  cases. 

The  seriousness  of  measles  in  epidemics  among  uncivilized 
peoples  has  always  been  recognized,  but  ordinarily  it  is  con- 
sidered too  lightly.  Bearing  in  mind  the  frequency  and  the 
severity  of  its  gravest  complication — bronchopneumonia — it 
is  one  of  the  most  fatal  and  serious  of  all  the  contagious 
diseases. 

The  period  of  incubation  of  measles  varies  between  seven 
and  eighteen  days ;  on  an  average  it  is  ten  days  after  exposure 
before  catarrhal  S3'mptoms  begin,  and  fourteen  days  before 
the  appearance  of  the  rash.  The  symptomatology  of  measles 
is  a  characteristic  one.  The  period  of  invasion  is  character- 
ized by  fever  tending  toward  remissions  to,  or  nearly  to,  the 
normal  temperature  range. 

We  find  also  coryza,  and,  in  fact,  a  catarrhal  condition  of 
the  nose,  eyes  and  bronchi,  with  slight  cough.  The  eyes  are 
congested  and  sensitive  to  light,  and  there  is  a  free  lachrymal 
discharge.  Pathognomonic  in  this  stage  is  the  appearance  of 
Koplik's  spots.  These  are  described  as  minute,  bluish-white 
spots,  often  with  a  red  areola,  occurring  upon  the  mucous 
membrane  of  the  mouth  as  early  as  the  first  day  of  the  inva- 
sion.    When  diffuse  they  are  very  easy  to  recognize. 

The  rash  usually  appears  upon  the  fourth  day,  though 
it  may  occur  earlier  or  later.  First  noticed  on  the  face  or 
neck,  the  eruption  begins  as  a  macular  type,  and  later  be- 
comes papular.  The  lesions  may  remain  discrete  or  become 
coalesced,  and  the  whole  body  is  soon  covered  with  the  erup- 


MEASLES.  18i 

tion,  which  may,  in  very  severe  cases,  become  hemorrhagic. 
The  rash  and  accompanying  symptoms  of  measles  may  range 
from  the  mildest  to  the  most  severe  conditions. 

Within  from  two  to  five  days  after  the  onset  and  full 
development  of  the  rash,  it  begins  to  fade,  the  other  symp- 
toms abate,  and  the  temperature  rapidly  falls  to  normal  in 
uncomplicated  cases.  As  the  rash  fades  it  almost  always 
leaves  a  characteristic  coppery  mottling  or  discoloration  of 
the  skin. 

Measles  might  be  confounded  with  scarlet  fever,  German 
measles,  and  the  incipient  stage  of  smallpox.  Except  under 
most  unusual  circumstances,  the  diagnosis  of  measles  is  very 
easy. 

TREATMENT. 

If  uncomplicated,  measles  requires  but  little  besides  gen- 
eral care.  A  case  of  measles  should  be  kept  in  a  room  not 
too  cool,  from  65°  to  70°  F.  (18.3°  to  21.1°  C).  The  patient 
should  be  well  protected  from  the  possibility  of  exposure  to 
changes  in  temperature  and  draughts,  and  the  room  should 
be  kept  dark  so  long  as  photophobia  and  congestion  of  the 
eyes  and  conjunctivae  persist.  The  bowels  must  be  kept  open, 
and  the  diet  in  the  febrile  stage  be  of  the  lightest  variety,  with 
water  given  freely. 

Stimulation  is,  as  a  rule,  not  needed,  unless  in  those 
asthenic  cases  of  measles  that  occasionally  are  met  with  dur- 
ing the  course  of  severe  epidemics.  The  renal  function  is  but 
rarely  impaired  in  measles.  When  slight  febrile  albuminuria 
occurs,  the  use  of  citrate  of  potassium  and  the  free  use  of 
water  practically  always  brings  about  prompt  abatement  of 
this  symptom. 

Should  the  rash  of  measles  be  not  well  shown,  it  is  my 
practice  to  bring  it  out  by  the  use  of  a  hot  bath,  due  precau- 
tions being  taken  that  the  patient  does  not  take  cold.  Other 
local  treatment  is  not  required.  Proper  and  sufificienth'  fre- 
quent cleansing  of  the  skin  aids  desquamation  and  shortens 
its  duration. 

The  eyes  of  the  measles  patient  require  protection  and 
cleansing.  In  the  mildest  of  cases  no  washing  ma}-  be  needed. 
If,  however,  special  care  be  necessar}-,  a  boric  acid  solution 


182  EXANTHEMATA. 

will  usually  be  found  sufficient.  If  this  does  not  fully  answer 
the  purpose,  instillations  of  10  per  cent,  argyrol  solution  once 
or  twice  daily  will  hasten  a  cure.  The  lids  become  inflamed 
in  the  presence  of  free  discharge,  and  require  the  application 
of  some  bland  ointment,  such  as  the  ointment  of  the  yellow 
oxid  of  mercury  in  the  strength  of  1  grain  (0.065  Gm.)  to  the 
ounce  (30  mils). 

Should  symptoms  of  keratitis  or  corneal  ulcer  supervene, 
a  specialist  should  be  consulted. 

The  condition  of  the  respiratory  tract  should  always  be 
kept  under  close  observation  in  measles.  A  mild  catarrhal 
laryngitis  is  very  common  in  measles,  but  this  requires  no 
particular  treatment.  The  chief  importance  of  more  severe 
grades  of  laryngitis  complicating  measles  lies  in  their  possible 
confusion  with  a  diphtheria  complicating  the  disease.  It  is 
well  known,  and  should  always  be  borne  in  mind,  that  measles 
predisposes  to  diphtheria. 

Bronchopneumonia  as  a  complication  of  measles  is  of  the 
utmost  importance,  as  it  is  the  chief  cause  of  the  very  appre- 
ciable death-rate  in  this  disease.  Its  onset  may  be  looked  for 
during  the  eruptive  period,  and  if,  when  the  rash  fades,  the 
lungs  do  not  clear  up  and  the  temperature  remains  above  nor- 
mal, we  should  at  once  suspect  some  grave  pulmonary  lesion. 

The  treatment  of  bronchopneumonia  and  other  complica- 
tions, such  as  otitis  media,  in  measles  does  not  differ  from 
that  employed  in  children  when  they  arise  from  any  other 
cause. 

The  treatment  of  the  complications  of  measles,  and  espe- 
cially bronchopneumonia,  is,  and  should  really  be,  largely 
prophylactic.  If  due  regard  be  given  this  in  preserving  a 
proper  temperature  of  the  room,  with  sufficient  aeration,  and 
if  the  patient  be  kept  in  bed  until  a  complete  cure  has  been 
effected,  pulmonary  complications  will  be  rare.  In  patients 
who  are  weakly  and  the  possible  subjects  of  tuberculosis  in 
any  form,  care  should  be  exercised  for  a  number  of  months 
after  an  attack  of  measles,  in  order  to  avoid  such  possible 
after-effects. 


GERMAN   MEASLES.  183 

GERMAN    MEASLES. 

German  measles,  or  rubella,  is  a  specific  and  infectious 
fever,  of  short  duration,  attended  by  few  constitutional  symp- 
toms, and  characterized  by  a  papular  or  macular  eruption. 

As  a  disease  German  measles  is  a  distinct  entity,  in  spite 
of  the  prolonged  discussions  that  have  arisen  as  to  its  true 
nature.  It  is  in  nowise  connected  with  scarlet  fever  or 
measles;  it  is  neither  of  these  diseases  in  modified  form,  nor 
is  it  a  hybrid  between  the  two. 

The  contagiousness  of  German  measles  is  much  less  than 
that  of  measles,  and  for  that  reason  widespread  epidemics  are 
seldom  seen.  It  occurs  with  the  greatest  frequency  during 
the  spring  and  early  summer  months.  From  the  experience 
of  most  contagious  hospitals,  it  would  seem  that  the  disease 
occurs  with  exceptional  frequency  in  young  adults.  It  is  sel- 
dom met  with,  however,  in  persons  over  30  years  of  age.  Sex 
appears  to  be  without  influence  upon  its  incidence. 

The  disease  is  most  contagious  when  the  eruption  is  at  its 
height.  The  nature  of  the  contagion  is  not  known ;  it  is  most 
probable  that  this  resides  in  the  catarrhal  discharges.  The 
mode  of  infection  is  by  direct  contact  of  the  sick  with  the 
well.  It  is  rare  that  third  parties  or  fomites  play  the  role  of 
carrier. 

The  incubation  period  varies  from  twelve  days  to  three 
weeks.     The  average  is  fourteen  days. 

The  classical  symptoms  of  German  measles  are  malaise, 
mild  coryza,  fever,  and  the  rash.  Swelling  and  tenderness  of 
the  lymphatic  glands  is  an  early  symptom  in  most  cases. 
Enlargement  of  the  post  cervical  glands  is  considered  of 
diagnostic  value  by  many.  Suppuration  of  the  lymphatic 
glands  is  never  known.  As  a  rule,  the  rash  and  slig'ht  fever 
will  be  the  only  symptoms.  The  fever  in  the  milder  cases 
may  remain  at  normal  during  the  entire  course  of  the  disease ; 
on  the  other  hand,  it  may  go  as  high  as  104°  or  105°  F.  (40° 
or  40.6°  C.).  A  curious  and  important  fact  is  that  with  the 
very  high  fever  there  is  no  prostration.  Very  rarely  does  the 
patient  appear  uncomfortably  or  seriously  ill.  The  fever 
returns  to  normal  before  the  complete  fading  of  the  rash. 


184  EXANTHEMATA. 

The  rash  shows  first  on  the  face,  and  rapidly  extends  to 
the  trunk  and  extremities.  It  begins  as  small,  very  slightly 
elevated  papules,  fairly  discrete,  and  similar  somewhat  to 
those  of  measles.  These  fade  quickly,  and  leave  behind  no 
staining  or  mottling  of  the  skin.  The  duration  varies,  as  a 
rule,  from  twenty-four  to  forty-eight  hours;  it  may,  however, 
remain  out  for  so  short  a  time  as  twelve  hours,  and,  again, 
may  last  for  four  or  five  days. 

Complications,  sequelse,  or  relapses  we  do  not  see.  It  is 
possible  that  second  attacks  do  occur,  but  they  are  certainly 
very  rare.  Recovery  is  the  unvarying  rule.  I  have  frequently 
noted  with  much  interest  the  little  disturbance  caused  by  an 
attack  of  German  measles  in  patients  already  the  subjects  of 
other  diseases,  such  as  scarlet  fever  and  true  measles. 

The  diagnosis  is  the  most  important  feature  in  the  hand- 
ling of  German  measles.  Failure  to  diagnose  the  disease  cor- 
rectly has  been  the  source  of  much  embarrassment  to  health 
authorities,  and  of  great  humiliation  to  the  attending  phy- 
sician. The  diseases  from  which  it  should  be  differentiated 
always  are  scarlet  fever  and  true  measles,  particularly  the 
former.  Other  and  less  important  conditions  with  which  it 
may  be  confused  are  rashes  due  to  drugs,  and  to  errors  of  diet. 

TREATMENT. 

There  is  no  contagious  disease  which  requires  so  little 
treatment.  Rest  in  bed  until  two  or  three  days  after  disap- 
pearance of  the  rash  will  be  all-sufificient.  In  a  few  days  more 
the  patient  may  be  allowed  out-of-doors  on  quiet,  sunny  days. 
Should  there  be  fever,  a  light  diet  should  be  enforced  until  the 
return  of  the  temperature  to  normal.  Ten  days  after  the 
appearance  of  the  eruption  the  patient  should  be  considered 
fit  for  discharge. 


Tropical  Diseases 


VICTOR   G.    REISER,    M.D,    D.Sc, 

Director  for  the  East,  International  Health  Board,  Rockefeller  Founda- 
tion; Formerly  Director  of  Health  for  the  Philippine  Islands  and 
Professor  of  Hygiene  and  Sanitation,  College  of  Medicine  and 
Surgery,    University  of   the  Philippines. 


(185) 


Tropical  Diseases. 


FOREWORD. 


One  of  the  most  satisfactory  things  connected  with  trop- 
ical medicine  is  the  fact  that  the  more  important  diseases  are 
preventable.  Their  prophylaxis  is  well  understood.  Modern 
medicine  has  probably  received  its  greatest  renown  through 
the  discoveries  made  in  the  prevention  and  cure  of  tropical 
diseases.  The  conclusive  proof  that  the  mosquito  conveys 
filariasis,  malaria  and  yellow  fever,  that  beriberi  is  due  to 
improper  diet,  that  cholera  and  hookworm  are  contracted 
through  contact  with  human  feces,  and  the  conclusive  results 
that  have  followed  the  application  of  the  indicated  measures, 
are  among  the  brightest  pages  in  medical  history.  The  lives 
saved  already  run  into  the  hundreds  of  thousands,  and  the 
distress  and  suffering  avoided  goes  into  the  millions. 

The  object  of  this  section  is  only  to  give  brief  descriptions 
of  a  few  of  the  more  important  diseases,  and  to  afford  a  ready 
reference  to  those  commonly  found  in  the  tropics.  In  these 
days  of  rapid  communication  residents  of  warm  countries  fre- 
quently call  upon  the  doctor  of  temperate  zones  for  medical 
relief,  so  physicians  of  all  climes  have  an  added  incentive  to 
acquaint  themselves  with  the  diseases  of  all  regions. 

The  strides  in  tropical  medicine  are  so  rapid  that  unless 
the  subject-matter  is  constantly  revised  and  brought  up  to 
date,  it  is  of  very  little  practical  value.  While  it  is  not  pri- 
marily the  purpose  in  this  chapter  to  dwell  upon  hygiene, 
sanitation  and  prophylaxis  of  tropical  disease,  yet  these  fac- 
tors are  so  intimately  associated  with  the  subject  that  a  brief 
resume  of  the  modern  methods  in  this  regard  will  be  included. 

LEPROSY. 

Leprosy  is  a  chronic  infectious  disease  caused  by  the 
Bacillus  Icprcc,  and  usually  occurs  in  one  of  three  types.  When 
the  principal  disturbance  consists  of  anatomic  changes  in  the 

(187) 


188  TROPICAL   DISEASES. 

nervous  system,  accompanied  by  loss  of  sensation  and  atro- 
phy, it  is  referred  to  as  anesthetic  leprosy.  When  it  is  char- 
acterized, by  the  presence  of  tubercular  nodules  in  the  skin 
and  mucous  membranes,  it  is  called  tubercular  or  hypertrophic 
leprosy.  When  it  is  a  combination  of  these  two  types,  it  is 
called  mixed  leprosy. 

In  the  struggle  between  man  and  disease  there  is  no 
malady  which  has  aroused  greater  universal  sympathy,  and, 
until  recently,  has  bafiled  all  efforts  toward  successful  treat- 
ment. Leprosy  is  one  of  the  first  diseases  of  which  we  have 
a  record.  Mention  is  made  of  it  in  Egypt  1500  b.  c.  It  is 
described  in  the  Bible.  It  was  common  in  Italy  during  the 
time  of  Pompey,  and  subsequently  extended  to  all  parts  of 
the  earth.  The  movement  caused  by  the  Crusades  was  prob- 
ably responsible  for  the  transmission  of  leprosy  to  Western 
Europe,  and  its  appearance  in  epidemic  form. 

Greek  writers,  perhaps,  have  given  the  best  of  the  early 
descriptions  of  leprosy.  For  instance,  the  following  is  from 
Aretseus : 

"Shining  tubercles  of  different  size,  dusky  red  or  livid  in 
color,  on  face,  ears  and  extremities,  together  with  a  thickened 
and  rugous  state  of  the  skin,  a  diminution  or  total  loss  of  its 
sensibility,  and  a  falling  off  of  all  the  hair  except  that  of  the 
scalp.  The  disease  is  described  as  very  slow  in  its  progress, 
sometimes  continuing  for  several  years  without  materially 
altering  the  functions  of  the  patient.  During  this  continuance 
great  deformity  is  generally  produced.  The  alge  of  the  nose 
become  swollen,  the  nostrils  dilate,  the  lips  are  tumid ;  the 
external  ears,  especially  the  lobes,  are  enlarged  and  thickened 
and  beset  with  tubercles;  the  skin  of  the  cheek  and  forehead 
grows  thick  and  tumid  and  forms  large  and  prominent  rugae, 
especially  over  the  eyes ;  the  hair  of  the  eyebrows,  beard, 
pubes  and  axillse  falls  off;  the  voice  becomes  hoarse  and 
obscure,  and  the  sensibility  of  the  parts  affected  is  obtuse  or 
totally  abolished,  so  that  pinching  or  puncturing  gives  no 
uneasiness.  This  disfiguration  of  the  countenance  suggested 
the  idea  of  the  features  of  a  satyr,  or  wild  beast;  hence  the 
disease  was,  by  some,  called  satyriasis,  or  by  others  leontiasis. 
As  the  malady  proceeds  the  tubercles  crack  and  ultimately 
ulcerate.     Ulcerations   also   appear  in  the   throat  and  nose, 


LEPkOSV.  189 

which  sometimes  destroy  the  palate  and  septum,  the  nose 
falls,  and  the  breath  is  intolerably  offensive ;  the  fingers  and 
toes  gangrene  and  separate  joint  after  joint." 

Leprosy  increased  in  Europe  in  the  days  of  Pompey.  In 
the  thirteenth  century  it  became  epidemic.  Stern  measures 
were  enforced,  and  lepers  were  isolated  in  colonies.  They 
were  often  required  to  wear  special  dress  or  to  ring  a  bell 
when  passing  along  the  street.  They  were  forbidden  to  drink 
at  public  fountains,  or  to  touch  children,  or  to  eat  with  per- 
sons other  than  lepers.  The  church  performed  the  funeral 
service  over  persons  who  were  diagnosed  as  lepers,  and  they 
were  regarded  as  dead.  This  latter  provision  is  said  to  be 
still  carried  out  in  order  to  permit  lepers  who  have  non- 
leprous  husbands  or  wives  to  marry  leper  inmates  of  colonies. 
The  West  Indies  gradually  became  infected,  probably  through 
the  Negro  slave  trade.  The  disease  was  carried  to  North 
America,  where  it  has  been  slow  in  spreading.  About  the 
same  time  it  was  carried  to  South  America,  where  it  has 
flourished,  especially  in  Brazil  and  Venezuela.  In  Africa  it 
was  first  reported  in  the  South  in  1756,  and  is  said  to  have 
been  carried  there  by  the  Dutch.  Since  that  time  the  disease 
in  Africa  is  said  to  have  increased  mainly  among  the  East 
Indian  troops.  In  Biblical  and  other  older  writings  it  is  more 
than  likely  that  diseases  described  as  leprosy  are  often  some 
other  disfiguring  skin  diseases  which  resemble  it.  There  is 
much  reason  to  believe,  for  instance,  that  frambesia  exists  in 
three  stages,  like  syphilis,  and  that  in  the  third  stage  the 
lesions  and  deformities  are  often  mistaken  for  leprosy.  Sy- 
philis, psoriasis,  tubercular  ulcers,  madura  foot,  ichthyosis 
and  other  skin  affections  have  undoubtedly  been  mistaken  for 
leprosy  in  the  past.  The  diagnosis  was  not  placed  upon  a 
scientific  basis  until  the  discovery  of  the  bacillus  by  Hansen, 
which  is  now  known  by  his  name.  Failure  to  cultivate  the 
bacillus  has  probably  been  one  of  the  greatest  stumbling- 
blocks  in  developing  a  satisfactory  treatment.  The  disease 
has  gradually  disappeared  in  those  countries  in  which  effec- 
tive efforts  have  been  made  to  isolate  those  suffering  from  the 
disease.  It  may  be  regarded  as  axiomatic  that  no  new  case 
of  leprosy  occurs  in  any  geographic  area  unless  there  has  been 
a  human  leper  there  before. 


190  TROPICAL   DISEASES. 

Many  authors  hold  that  at  the  present  time  leprosy  is  more 
particularly  a  disease  of  tropical  and  subtropical  countries. 
The  "fact  that  this  distribution  does  correspond  with  those 
latitudes  does  not  necessarily  mean  that  there  is  anything 
peculiar  about  the  climate  which  promotes  the  transmission 
of  leprosy.  The  fact  that  in  most  temperate  countries  isola- 
tion is  more  rigidly  carried  out,  and  that  therefore  there  is  not 
the  same  opportunity  for  the  spread  of  the  disease,  may  be  the 
real  explanation.  Leprosy  is  very  common  in  some  cold  coun- 
tries, notably  in  Finland,  Norway  and  Sweden.  It  is  also 
reported  to  be  common  in  Russia,  near  Riga,  but  there  are  no 
reliable  data  with  regard  to  this  point.  In  the  United  States 
the  two  States  having  the  greatest  numbers  are  Louisiana  and 
Minnesota,  the  first  being  subtropical,  and  the  other  extremely 
cold.  In  Hawaii  the  disease  spread  rapidly  after  1860,  and 
strenuous  efforts  to  stamp  it  out  have  not  succeeded  in  greatly 
reducing  the  incidence.  A  search  through  the  literature  fails 
to  show  any  report  of  the  disease  before  1848.  In  1865  there 
were  230  known  lepers  in  a  population  of  67,000;  by  1891  there 
were  1500  lepers  in  a  population  of  44,000,  or  one  in  thirty. 
There  is  much  reason  to  believe,  however,  that  segregation  of 
lepers  has  not  been  effectively  carried  out  in  the  Hawaiian 
Islands.  It  cannot  be  very  well  charged  that  isolation  has 
failed  to  stamp  out  the  disease,  because  isolation  has  not  been 
given  a  fair  trial.  Leprosy  is  also  common  in  some  South 
American  countries,  notably  in  Brazil,  Venezuela,  Ecuador, 
Argentina  and  Colombia. 

It  is  more  than  likely  that  leprosy  is  much  more  common 
today  than  is  generally  suspected,  especially  in  countries 
regarded  as  more  or  less  free  of  the  disease.  It  is  estimated 
that  in  India,  among  a  population  of  210,000,000,  there  are 
105,000  lepers.  This  gives  a  ratio  of  one  to  2000.  There  are 
various  estimates  of  the  number  of  lepers  in  Japan,  but  a  con- 
servative figure  would  perhaps  be  50,000.  Calculating  the 
population  of  Japan  at  50,000,000,  this  would  give  an  incidence 
of  one  to  1000.  In  the  Philippine  Islands,  with  a  population 
of  approximately  8,000,000,  10,000  lepers  were  collected  be- 
tween 1906  and  1914.  It  is  not  likely  that  there  were  more 
than  6000  cases  of  leprosy  during  any  one  year.  This  would 
give  a  ratio  of  one  to  1400.    It  is  usually  asserted  that  leprosy 


LEPROSY.  191 

is  more  common  among  those  of  uncleanly  habits,  where  there 
is  squalor,  dirt  and  poverty.  The  dark  skinned  races  were 
thought  to  be  especially  susceptible.  A  rough  calculation  of 
the  number  of  Americans  who  have  been  in  the  Philippines 
shows  that  the  ratio  among  them  is  about  one  to  1400,  which 
is  the  same  as  that  for  the  Filipinos.  A  recent  calculation  of 
the  number  of  lepers  in  Java  shows  that  the  incidence  of  the 
disease  is  apparently  as  great  among  the  Europeans  as  among 
the  natives.  In  China  the  disease  is  very  common  in  the 
Southern  part,  and  apparently  rare  in  Northern  China.  In 
India  there  is  a  similar  disproportion  between  the  number  in 
the  North  and  in  the  South.  New  Caledonia  is  another  coun- 
try into  which  the  disease  was  introduced  in  comparatively 
recent  times.  The  first  record  of  it  was  in  1865,  and  it  was' 
presumably  introduced  by  Chinamen.  There  are  now  prob- 
ably 5000  lepers  in  New  Caledonia.  In  countries  where  public 
health  and  sanitation  are  exceptionall}^  good,  leprosy  may 
occur.  New  Zealand,  for  instance,  with  a  population  of 
1,000,000,  is  reported  to  have  five  lepers,  or  one  in  200,000. 
Australia,  with  a  population  of  6,000,000,  is  reported  to  have 
thirty  lepers,  or  one  in  200,000.  The  United  States,  with  a 
population  of  100,000,000,  has  perhaps  1000  lepers,  or  one  in 
100,000. 

For  convenient  reference  the  following  table  is  submitted 
as  a  rough  estimate  of  the  proportion  of  lepers  to  the  popula- 
tion in  different  countries : 

Japan    

Philippine    Islands     

India    

United   States    

New   Zealand    

Australia    


1.000 

1.400 

2,000 

100,000 

200,000 

200,000 

A  small  rod-like  organism  closely  reseinbling  the  tubercle 
bacillus  discovered  by  Hansen  of  Bergen  in  1871  is  very  gen- 
erally recognized  as  the  cause  of  the  disease.  Many  efforts 
have  been  made  to  cultivate  the  micro-organism,  but  so  far 
without  demonstrable  success. 

There  is  no  definite  information  available  as  to  the  method 
by  which  the  disease  is  transmitted.  It  is  generally  held  that 
it  may  take  place  by  inoculation,  and  in  support  of  this  the 


192  TROPICAL   DISEASES. 

case  of  the  Hawaiian  convict  is  usually  quoted.  This  pris- 
oner, who  was  under  sentence  of  death,  was  inoculated  on 
September  30,  1884,  by  Arning.  Four  weeks  later  he  had 
rheumatoid  pains  and  gradual  painful  swellings  in  the  ulnar 
and  median  nerves.  The  neuritis  gradually  disappeared,  and 
then  a  small  leprous  tubercle  developed  at  the  site  of  the 
inoculation.  In  1887  the  disease  was  quite  manifest,  and  the 
man  died  six  years  after  inoculation.  However,  the  case  is 
not  regarded  as  conclusive,  because  the  man  had  leprous  rela- 
tives and  lived  in  a  leprous  country.  It  is  not  likely  that  the 
disease  can  be  transmitted  through  heredity.  A  most  careful 
examination  of  fifty  children  born  of  leprous  parents  at  the 
Culion  Leper  Colony  did  not  result  in  the  discovery  of  a 
single  case  of  leprosy.  One  of  these  children  developed 
leprosy  at  the  age  of  2  years.  However,  this  child  lived  at 
the  leper  colony  in  close  intimate  contact  with  its  mother,  and 
probably  contracted  the  disease  there  after  birth.  It  is  very 
difficult  to  show  that  leprosy  is  contracted  through  contagion. 
An  ulcer,  or  the  terminal  effects  of  an  ulcer,  located  at  the 
junction  of  the  cartilaginous  and  bony  portion  of  the  septum 
of  the  nose,  in  which  are  imbedded  leprosy  bacilli,  is  one  of 
the  most  constant  signs  of  the  disease.  It  is  possible  that 
contagion  may  be  given  out  to  the  surrounding  air  through 
open  ulcers  of  this  kind  which  contain  leprosy  bacilli.  Glass 
plates  that  have  been  exposed  to  the  breath  of  such  persons 
have  resulted  in  the  finding  of  leprosy  organisms.  Later, 
however,  considerable  doubt  has  been  thrown  upon  these 
experiments,  because  it  not  infrequently  happens  that  an  acid- 
fast  bacillus  can  be  found  in  the  greasy  exudates  of  the  face 
which  may  not  be  leprosy  bacilli.  At  times  cases  of  leprosy 
occur  in  communities  where  there  is  apparently  no  connection 
with  a  previous  case.  Such  an  instance  occurred  a  few  years 
ago,  in  Indiana,  in  an  old  negro  woman  who  had  never  been 
out  of  the  State ;  the  diagnosis  in  this  instance  was  well 
authenticated,  and  it  is  generally  reported  that  there  are  no 
other  cases  of  leprosy  in  Indiana.  During  the  present  year 
(1917)  another  case  has  been  reported,  but  the  infection  is 
believed  to  have  taken  place  outside  of  the  State.  However, 
it  is  very  difficult  to  be  dogmatic  as  to  the  absence  of  leprosy 
in  Indiana,  and  more  detailed  information  with  regard  to  the 


LEPROSY.  193 

case  might  show  that  the  woman  had  been  in  contact  with  a 
leper.  It  is  also  frequently  stated  that  washerwomen  are 
more  susceptible  to  leprosy  than  others.  Statistics  of  the 
occupations  of  10,000  lepers  in  the  Philippines  show  that  there 
is  no  special  disproportion  among-  the  various  occupations. 

There  is  considerable  evidence  that  infection  may  take 
place  through  food.  There  is  no  record  of  leprosy  having 
been  contracted  on  a  leper  colony  in  which  food  contamina- 
tion could  be  clearly  excluded. 

Sexual  intercourse  also  seems  to  be  frequently  responsible, 
but  that  it  is  not  the  only  mode  of  infection  is  clearly  shown 
by  the  fact  that  2-year-old  children  have  been  known  to  ac- 
quire the  disease. 

As  a  rule,  doctors  and  nurses  in  leper  colonies  do  not  con- 
tract the  disease,  although  there  are  a  number  of  notable 
exceptions.  One  of  the  best  known  cases  is  that  of  Father 
Damien,  who  became  a  leper  at  Molokai,  in  the  Hawaiian 
Islands.  There  is,  likewise,  the  case  of  Father  Boblioli,  at 
New  Orleans,  and  more  recently  (1915),  the  case  of  the  Span- 
ish priest,  who  contracted  the  disease  after  having  served  as 
chaplain  at  the  Culion  Leper  Colony  for  more  than  two  years. 
An  investigation  in  the  Philippine  Islands  showed  consider- 
able evidence  that  leprosy  may  be  regarded  as  a  house  dis- 
ease. In  enforcing  the  law  for  the  segregation  of  lepers  it  has 
been  customary  there  to  examine  once  a  year  the  inmates  of 
houses  from  which  lepers  have  been  taken.  Exact  statistics 
are  not  available,  but  a  fair  percentag'e  of  incipient  cases  of 
leprosy  have  been  detected  in  the  Philippines  in  this  way  dur- 
ing the  past  few  years.  Whether  the  disease  was  contracted 
by  the  contacts  througii  prolonged  intimate  association  with 
the  leper  who  was  removed,  or  whether  it  may  have  been  con- 
veyed by  the  means  of  bedbugs  or  other  insects,  is  a  much- 
mooted  question.  There  are  many  hundreds  of  instances  on 
record  in  which  either  the  husband  or  the  wife  was  a  leper 
and  full  marital  relations  were  maintained  over  a  period  of 
more  than  ten  years,  yet  no  infection  took  place.  Kitasato 
gives  the  following  table^  of  infections: 

Children  of  lepers   7.05% 

Matrimonial  infections   8.8% 

Brother  and  sister   4.2% 

13 


194  TROPICAL   DISEASES. 

Leprosy  bacilli  have  frequently  been  found  in  bedbugs 
that  have  fed  on  leprous  persons,  but  it  has  not  been  possible 
satisfactorily  to  demonstrate  that  these  bugs  eject  the  organ- 
ism when  they  bite  at  a  later  time.  It  has  been  suggested 
that  the  fecal  discharges  of  the  bedbug  or  other  insect  may 
be  deposited  on  the  skin,  and  through  scratching  or  otherwise 
the  infection  may  find  its  way  into  the  body  through  the 
wound  made  by  the  insect  or  by  way  of  some  other  abrasion. 

There  is  a  remarkable  regularity  of  sex  incidence  in  the 
disease.  Regardless  of  what  part  of  the  world  leprosy  is 
found,  there  are  practically  always  two  males  for  every  female 
leper.  In  other  words,  they  generally  go  by  thirds.  In  any 
given  community  a  third  of  the  lepers  are  women. 

Usually  the  incubation  period  is  calculated  in  years.  The 
lowest  known  reliable  record  is  that  of  an  18-months-old 
infant.  There  have  been  cases  reported  up  to  twenty-seven 
years  after  the  last  known  exposure.  Two  or  three  years, 
however,  may  be  regarded  as  a  fair  average  incubation  period. 

The  study  of  leprosy  has  been  very  much  retarded,  owing 
to  the  fact  that  no  animal  is  known  to  contract  the  disease, 
and  also  by  the  difficulty  in  cultivating  the  leprosy  organism. 
Much  work  has  been  done  in  recent  years  in  cultivating  the 
micro-organism,  and  the  general  opinion  seems  to  prevail  that 
leprosy  bacilli  can  be  grown  in  the  form  of  a  streptothrix, 
which  later  may  become  the  characteristic  rod  of  leprosy.  It 
is  quite  noteworthy  that  many  persons  trace  the  first  symp- 
toms of  leprosy  to  a  prolonged  exposure  to  salt  water.  This 
is  quite  a  common  belief  among  many  of  the  islanders  of  the 
Pacific.  Faint  skin  eruptions  in  leprosy  often  become  very 
prominent  after  a  hot  bath. 

Leprosy  bacilli  have  also  been  found  in  the  probosces  of 
flies  and  upon  their  feet.  It  is  quite  conceivable  that  they 
might  infect  food  or  open  wounds  of  non-leprous  persons. 
Scabies  is  a  skin  disease  which  is  very  frequently  associated 
with  leprosy,  but  whether  it  has  any  direct  connection  with 
leprosy  has  not  been  proved.  It  may  be  due  to  the  fact  that 
scabies  is  particularly  common  among  lepers  owing  to  their 
uncleanly  habits.  It  is  a  frequent  custom  among  Latins  and 
races  of  the  Pacific  not  to  take  baths  when  they  are  ill  or 
have  a  fever.     For  this  reason  some  lepers  do  not  bathe  for 


LEPROSY.  195 

years,  and  a  disease  like  scabies  may  thrive  under  these  cir- 
cumstances. The  scabies  itch-mite  is  at  times  undoubtedly 
infected  with  leprosy  bacilli,  and  owing-  to  its  burrowing 
habits,  it  is  quite  conceivable  that  it  might  transmit  the  dis- 
ease to  others. 

With  regard  to  transmission,  the  whole  question  may  be 
summed  up  as  follows :  There  are  no  reliable  data  as  to  the 
manner  in  which  leprosy  is  conveyed.  So  far  no  tenable 
hypothesis  has  been  presented.  Most  of  the  evidence  avail- 
able shows  that  the  disease  usually  occurs  after  prolonged 
intimate  contact  with  a  leper.  This  usually  means  sleepmg 
in  the  same  bed  or  in  small  rooms  with  a  leper  for  periods  of 
weeks  or  months,  or  through  marital  relations,  or  through  the 
close  relationship  which  exists  between  a  child  and  its  leprous 
mother.  Whether  the  transmission  is  due  to  expired  air,  to 
the  facilities  given  for  insect  transmission,  to  direct  or  indirect 
contact,  to  infected  food,  or  to  other  relationship  associated 
with  close  living  conditions,  is  not  known. 

The  mode  of  entrance  of  the  bacillus  of  leprosy  into  the 
human  host  is  unknown.  The  respiratory  passages,  and  espe- 
cially the  mucous  membrane  of  the  anterior  part  of  the  sep- 
tum, have  been  under  strong  suspicion.  There  is  much  reason 
to  believe  that  at  times  the  bacillus  does  enter  through  the 
alimentary  canal  or  through  the  generative  organs.  Insect 
transmission,  or  direct  contamination  through  the  skin,  also 
seems  possible.  The  nature  of  the  initial  lesion,  however,  is 
unknown.  The  bacilli  multiply  enormousl}^  after  they  have 
once  entered  the  body.  Large  numbers  may  frequently  be 
found  in  the  hair  follicles  and  in  the  deeper-seated  sections  of 
the  sweat  tubules.  There  is  no  general  agreement  as  to  the 
first  pathologic  lesion.  Recent  observations  indicate  that  in 
bone  invasions  the  bacilli  may  be  imbedded  in  a  fat-like  sub- 
stance. All  leprous  lesions  usually  show  enormous  numbers 
of  bacilli,  enclosed  in  plasma  cells,  about  the  exact  nature  of 
which  there  is  much  dispute.  These  cells,  containing  large 
numbers  of  liacilli,  are  very  characteristic  of  leprosy,  and  are 
generally  referred  to  as  "lepra  cells."  Often,  however,  tliere 
are  large  numbers  of  bacilli  imbedded  in  a  mucus-like  sub- 
stance. Sometimes  typical  giant  cells,  known  as  Langhan's 
cells,  are  seen.     Ordinarily  the  bacilli  do  not  invade  the  sur- 


196  TROPICAL   DISEASES. 

face  of  the  epithelia  nor  the  layer  of  the  cutis  directly  below 
the  epidermis.  A  typical  leproma  shows  superficial  epithe- 
lium, normal  in  appearance,  except  for  the  absence  of  an 
interpapillary  process.  Below  the  epithelium  there  is  a  layer 
of  connective  tissue,  usually  free  from  bacilli,  and  under  this 
is  found  the  typical  lesion,  composed  of  lepra  cells,  plasma 
cells  and  connective-tissue  cells.  The  walls  of  the  blood- 
vessels are  thickened  and  infiltrated,  sometimes  to  the  extent 
of  complete  obliteration.  In  the  lymph-spaces  the  globi  of 
the  older  writers  filled  with  bacilli  are  found.  The  attacks 
of  leprous  fever,  which  occur  so  regularly,  may  be  explained 
by  the  dissemination  of  the  bacilli  throughout  the  body  by  the 
blood-stream,  the  germs  being  enclosed  in  large  mononu- 
clear leucocytes.  Lesions  may  remain  stationary  for  years, 
and  retrogression  often  takes  place,  either  spontaneously  or 
as  the  result  of  treatment.  It  is  assumed  that  the  leproma 
press  on  the  nerves,  thus  causing  degeneration  of  the  neu- 
rilemma, and,  later,  distintegration  of  the  arteries  and  destruc- 
tion of  the  nerve  fibers.  Some  observers  state  that,  not  only 
are  the  peripheral  nerves  affected,  but  the  bacilli  attack  the 
anterior  cornua  of  the  spinal  cord.  Statistics  show  that  about 
50  per  cent,  of  lepers  who  have  been  examined  are  positive 
to  the  Wassermann  reaction,  but  as  frambesia  and  syphilis 
occur  in  so  many  of  the  lepers  who  have  been  examined,  it 
cannot  be  stated  that  the  Wassermann  reaction  is  necessarily 
associated  with  leprosy.  Efforts  to  recover  the  bacilli  in  the 
blood-stream  have  been  very  disappointing,  and  there  is  con- 
siderable doubt  as  to  the  reliableness  of  the  reports  v^hich 
claim  success  in  this  respect. 

The  leproma  is  usually  situated  in  the  cutis,  covered  by 
the  epidermis,  but  it  may  lie  in  the  subcutaneous  tissue,  in 
which  case  it  does  not  form  a  tubercle.  These  nodules,  or 
tubercles,  are  yellowish  white  in  color,  firm  in  consistence, 
and,  if  squeezed,  usually  a  little  clear  fluid  is  exuded.  The 
sweat,  sebaceous  glands,  and  hair  follicles  in  the  infected 
regions  are  usually  atrophied.  The  macules  consist  of  a  round 
cell  infiltration,  with  few  large  cells,  and  often  are  free  from 
bacilli.  The  spots  which  were  anesthetic  during  life  are 
usually  converted  largely  into  fibrous  connective  tissue,  and 
likewise  the  glands  and  hairs  in  them   atrophy  and  tend  to 


LEPROSY.  197 

disapppear.  The  liver  is  usually  enlarged  and  contains  infil- 
trated leprous  material.  The  ovaries  and  testes  often  show 
infiltration  and  fibrosis  of  the  interstitial  tissue,  which  de- 
stroys the  secretory  elements  and  causes  the  sterility  which 
is  usually  so  marked  among  lepers.  The  lymphatic  glands 
are  prone  to  become  large,  infiltrated,  and  filled  with  bacilli, 
especially  those  of  the  femoral  regions.  Nephritis  and  leprous 
infiltration  are  usual.  There  is  practically  always  marked 
infiltration  of  the  spleen,  and  lepra  bacilli  can  be  recovered 
from  this  organ.  The  nerves  most  markedly  affected  are  the 
ulnar,  the  median,  the  peroneal  and  the  posterior  til^ial.  They 
are  usually  much  thickened,  and  are  the  seat  of  a  fusiform 
reddish  gray  swelling  due  to  the  presence  of  leprous  tissue 
among  the  fibers.  The  spinal  cord  often  shows  posterior 
sclerosis  and  meningitis.  Periarteritis  and  endarteritis  are 
common.  Caries,  necrosis,  and  absorption  of  the  bones  are 
frequently  seen.  Trophic  changes  in  the  joints  and  perforat- 
ing ulcers  of  the  plantar  region  are  very  common  in  the  nerve 
form  of  the  disease ;  likewise  atrophy  of  the  interosseous  mus- 
cles, the  thenar  and  hypothenar  eminences.  There  has  been 
considerable  difference  of  opinion  as  to  whether  the  pulmo- 
nitis  so  frequently  found  in  leprosy  is  due  to  the  tubercle  or 
to  the  leprosy  bacilli.  In  more  careful  studies  made  recently 
it  has  been  shown  that  often  there  is  an  uncomplicated  leprous 
infiltration  of  the  lungs.  Tuberculosis  of  the  lungs  in  lepers 
is  common. 

Clinical  Forms  (Tubercular,  Nodular,  or  Hypertrophic). 
The  first  sign  of  leprosy  observed  is  usually  a  sharply  defined 
and  often  hyperesthetic  erythema.  In  a  small  percentage  of 
cases  the  earliest  evidence  of  the  disease  is  the  appearance  of 
small  areas  of  anesthesia  without  any  noticeable  alteration  of 
the  skin.  In  practically  all  cases,  however,  when  the  fore- 
going symptoms  are  due  to  leprosy,  a  careful  inspection  of 
the  nose  will  show  a  small  area  of  infiltration,  and  often  an 
ulcer  upon  the  septum  of  the  nose  located  at  the  junction  of 
the  cartilaginous  and  osseous  portions.  Even  when  there  are 
no  macroscopic  changes,  scarification  of  this  region  and  an 
examination  of  the  exuding  fluid  will  show  typical  leprosy 
bacilli.  In  a  great  majority  of  cases  of  tubercular  and  anes- 
thetic leprosy  macules  soon  appear.     These  may  vary  in  size 


198  TROPICAL   DISEASES. 

from  a  centimeter  to  areas  which  cover  a  large  part  of  the 
face,  or  even  the  back.  During  this  stage  the  disease  prog- 
resses very  slowly,  as  a  rule.  The  patient  often  gives  a  his- 
tory of  trying  various  skin  applications  for  a  period  of  one 
or  two  years  without  obtaining  relief.  The  characteristic 
nodules  appear  at  periods  varying  from  a  few  months  to  a 
number  of  years,  after  the  first  macules  or  infiltrations  into 
the  ears,  nose,  or  other  areas.  The  face  is  probably  affected 
more  frequently  than  any  other  part  of  the  body.  The 
nodules  may  vary  in  size  from  that  of  a  pea  to  that  of  a 
walnut,  or  sometimes  larger.  These  swellings  often  cause 
deformities  which  cause  the  face  to  resemble  that  of  a  lion, 
giving  rise  to  a  condition  commonly  referred  to  as  the  leonine 
facies.  Sometimes  the  body  is  so  studded  with  tubercles  as 
to  resemble  masses  of  small  red  potatoes  growing  out  every- 
where. Macules  or  tubercles  probably  do  not  occur  in  the 
scalp,  a  point  of  much  diagnostic  importance,  according  to 
Hopkins. 2  Macules  with  elevated  edges  are  very  common  on 
the  back,  and  these  lesions  often  clear  up  in  the  center  and 
spread  along  the  margins.  The  skin  which  has  been  affected 
by  the  disease  usually  becomes  atrophic  and  white.  The  so- 
called  typical  white  spots  of  leprosy  are,  however,  seldom  con- 
nected with  the  macules.  They  generally  occur  in  the  anes- 
thetic form  of  the  disease,  and  do  not  seem  to  be  associated 
with  inflammatory  reaction.  The  macules  often  progress  to 
crust  formations  resembling  psoriasis.  Occasionally  a  skin 
lesion  resembling  a  typical  birth-mark,  or  a  port  wine  mark, 
is  noted  as  one  of  the  earliest  signs  in  leprosy.  This  may 
occur  on  the  face,  the  forearm,  arms  or  legs.  Repeated  micro- 
scopic examinations  from  scrapings  made  from  these  lesions 
fail  to  reveal  tubercle  bacilli,  and  in  several  cases  observed  it 
was  impossible  to  find  tul^ercle  bacilli  in  scrapings  taken  from 
the  septum  of  the  nose.  After  these  cases  were  kept  under 
observation  for  a  period  of  about  six  months  it  was  possible 
to  demonstrate  leprosy  bacilli  in  the  lesions  and  coincidently 
in  the  nose.  Ulceration  is  not  common  in  uncomplicated 
tubercular  cases,  although  at  times  the  tubercles  break  down 
and  ulcerate.  Ulcers,  and  especially  perforating  ulcers  of  the 
feet,  seldom  occur  without  it  being  possible  to  demonstrate 
anesthetic  areas.     Upon  slight  injury  tubercles  may  undergo 


LEPROSY.  199 

ulceration.  The  tubercles  are  usually  reddish  brown  in  ap- 
pearance. The  loss  of  the  outer  half  of  the  eyebrows  occurs 
in  fully  half  of  the  cases  of  tubercular  leprosy. 

Infiltrations  without  distinct  nodular  formation  are  fre- 
quently among  the  earliest  symptoms  of  the  disease.  These 
are  generally  first  shown  by  the  swelling  of  the  lobes  of  the 
ears  and  alse  nasi.  Often  there  is  sufifusion  of  the  face,  which 
gives  the  appearance  often  noticed  in  photographs  of  persons 
which  are  slightly  out  of  focus.  Infiltrations  of  the  larynx 
are  also  common  and  provoke  huskiness  of  the  voice.  Infil- 
tration into  the  lungs  frequently  causes  symptoms  of  pneu- 
monitis. There  may  be  large  leprous  granulomata  located  in 
almost  any  portion  of  the  body  except  the  scalp.  Eye  lesions 
are  very  common  among  the  lepers  of  some  countries.  In 
Louisiana,  for  instance,  they  are  most  severe,  and  cause  suf- 
fering which  it  is  most  difficult  to  relieve.  Among  the  lepers 
of  the  Philippines  this  is  a  symptom  about  which  there  is  sel- 
dom complaint.  Blindness,  usually  due  to  infiltrations  and 
sometimes  to  ulcerations  of  the  cornea,  occurs  in  a  small  per- 
centage of  cases.  Infiltrations  in  the  nose  are  common  and 
cause  troublesome  blocking,  the  tissue  often  breaking  down 
and  the  nasal  discharges  containing  lepra  bacilli.  Fever  is 
seldom  noted  as  one  of  the  first  symptoms  in  the  disease.  It 
is  only  after  the  lesions  become  more  pronounced  that  attacks 
of  leprous  fever  are  noted.  These  usually  have  a  sudden 
onset  and  fall  by  lysis  in  the  course  of  three  or  four  days. 
These  febrile  attacks  may  occur  at  intervals  of  weeks  or 
months.     No  characteristic  changes  are  in  the  blood. 

Anesthetic  Leprosy.  In  this  form  of  the  disease  the  infil- 
tration is  principally  into  the  nerves.  The  onset  is  charac- 
terized by  shooting  pains,  especially  in  the  ulnar  and  peroneal 
nerves,  and  this  may  be  soon  followed  by  flushing  of  the  face, 
glossy  skin,  and  twitching  of  the  muscles.  Macular  eruption 
often  accompanies  the  anesthetic  form  of  the  disease.  By 
some  authorities  the  macular  eruption  is  regarded  as  an  infil- 
tration ;  by  others,  it  is  attributable  to  tissue  changes  in  the 
area  supplied  by  the  afifected  nerve.  After  the  infiltration  has 
persisted  for  some  time  the  nerves  can  usually  be  felt  as  stiff, 
hardened  cords,  the  ulnar,  brachial  and  peroneal  nerves  often 
being  readily  palpable. 


200  TROPICAL   DISEASES. 

The  macules  in  anesthetic  leprosy  are  usually  the  same  as 
in  the  tubercular  variety  of  the  disease,  except  that  they  occur 
with  great  frequency.  Large  areas  of  skin  are  often  found  to 
be  erythematous.  Erythema,  or  a  faint  eruption,  may  be 
greatly  intensified  by  heat  or  other  irritant,  so  that  a  diag- 
nosis which  otherwise  may  be  obscure  often  becomes  obvious 
after  a  hot  bath.  The  macules  commonly  resemble  the  ring- 
worm eruptions  so  frequently  seen  among  natives  in  tropical 
countries,  and  these  eruptions  frequently  disappear,  especially 
upon  the  application  of  ordinary  skin  lotions.  The  macules 
are  usually  clear  in  the  centers  and  spread  from  the  margins, 
and  may  coalesce  with  neighboring  macules.  Areas  that  may 
involve  a  square  foot  of  skin  surface  may  result.  A  small 
erythematous  patch  which  develops  into  a  bright  pink  macule 
on  a  clear  skin,  and  fails  to  heal  with  ordinary  treatment, 
should  be  regarded  with  considerable  suspicion.  Scrapings 
from  the  septum  of  the  nose  may  reveal  leprosy  bacilli  and 
show  the  true  nature  of  the  disease.  The  implication  of  the 
nerves  gradually  becomes  more  serious.  In  those  of  a  low 
order  of  intelligence  the  anesthesia  often  does  not  attract 
attention  until  the  patient  or  some  one  else  notices  that  they 
are  insensible  to  burns  or  that  they  have  no  sensation  about 
the  feet.  It  often  happens  that  the  patient  is  burned  with 
lighted  cigars  or  cigarettes,  or  otherwise,  without  being  aware 
of  it.  Anesthesia  of  the  feet  often  manifests  itself  by  the 
patient  being  unable  to  state  whether  he  is  wearing  footwear. 
When  blindfolded  and  barefooted  he  is  usually  unable  to  say 
whether  he  is  stepping  on  stone  or  wood  or  earth.  But  long 
before  these  symptoms  appear  careful  examination  would 
reveal  small  anesthetic  patches  on  the  back  or  in  the  areas 
supplied  by  the  ulnar,  median,  peritoneal,  or  other  nerves. 
The  ulnar  side  of  the  hand  and  the  outer  side  of  the  foot  are 
nearly  always  the  first  to  be  involved.  As  the  nerve  destruc- 
tion goes  on  the  reparative  process  stops,  slight  injuries  about 
the  extremities  fail  to  heal,  and  gradually  slow  ulceration  or 
absorption  takes  place,  until  the  fingers  or  toes  are  completely 
gone.  Owing  to  the  lack  of  repair,  lepers  who  play  musical 
string  instruments,  have  been  known  literally  to  wear  their 
fingers  away.  Perforating  ulcers  of  the  feet  in  anesthetic 
cases  are  also  quite  common.    These  are  most  difhcult  to  heal, 


LEPROSY.  201 

and  usually  occur  at  the  base  of  the  first  metatarsal  bone. 
Ulcers  over  the  anterior  surface  of  the  tibia  are  also  common. 
In  anesthetic  leprosy  the  eyebrows  are  seldom  affected.  Ab- 
sorption of  tissue  between  and  in  the  vicinity  of  cartilage  is 
likely  to  occur.  This  frequently  produces  considerable  dis- 
tortion of  the  nose,  and  deep  grooves  are  often  seen  between 
the  cartilaginous  joints  of  the  nose.  Atrophy  of  the  inter- 
osseous and  thenar  muscles  and  contractions  of  the  thuml) 
and  fingers  are  also  common.  The  "main  en  griff"  is  very 
characteristic  in  leprosy  (see  Fig.  3).  The  finger  joints  are 
ankylosed.  In  the  hands  the  area  corresponding  to  the  dis- 
tribution of  the  ulnar  nerve  is  first  affected.  In  right-handed 
persons  the  little  finger  of  the  right  hand  is  usually  the  first 
to  suffer.  In  areas  corresponding  to  the  distribution  of  the 
affected  nerve,  sensation  may  be  wholly  absent  or  greatly 
impaired.  In  the  back  distinction  sometimes  between  two 
needle  points  cannot  be  made  at  a  distance  of  2  inches  (5.08 
cm.)  or  more.  There  is  no  uniformity  between  the  lesions  or 
nerves  affected  on  the  two  sides  of  the  body.  Sometimes 
there  is  extreme  lacrymation  in  one  eye  and  none  in  the  other. 
One  side  may  have  marked  skin  lesions  or  anesthesia  and  the 
other  be  quite  free.  The  septum  of  the  nose  is  perhaps  even 
more  frequently  affected  in  the  anesthetic  form  than  in  the 
tubercular.  Absorption  of  bone  frequently  takes  place,  and 
through  muscular  contractions  many  odd  deformities  are  pro- 
duced, especially  in  the  extremities.  At  times  it  appears  as 
if  the  fingers  had  only  one  joint,  the  second  and  third  joints 
having  been  absorbed,  the  joint  with  the  finger-nail  being 
close  to  the  carpal  bones.  The  duration  and  progress  of  anes- 
thetic leprosy  is  usually  much  slower  and  more  prolonged 
than  is  the  rule  in  the  nodular  variety.  The  only  symptom 
for  many  years  may  be  a  slight  contraction  with  ankylosis  of 
the  little  finger.  Leprous  fever  in  the  anesthetic  form  seldom 
occurs,  and  is  never  so  severe  in  cases  in  w^hich  the  anesthetic 
symptoms  predominate  as  in  the  nodular  variety. 

Mixed  Leprosy,  Mixed  leprosy  is  simply  the  presence  in 
the  same  person  of  both  forms  of  the  disease  heretofore 
described,  in  varying  proportions,  and  represents  by  far  the 
great  majority  of  cases  found  in  leper  asylums.  There  may 
be  only  a  few  nodules,  with  marked  nervous  changes,  or  there 


202  TROPICAL   DISEASES. 

may  be  a  large  number  of  nodules  with  only  slight  nerve 
changes.  Almost  any  proportion  of  these  two  types  may  be 
present. 

The  only  really  satisfactory  and  conclusive  diagnosis  con- 
sists in  finding  the  typical  bundles  of  acid-fast  bacilli  char- 
acteristic of  leprosy.  As  already  noted,  these  can  usually  be 
found  earlier  in  a  scraping  taken  from  an  area  from  the 
septum  of  the  nose  at  the  junction  of  the  cartilaginous  and 
osseous  portion  than  anywhere  else.  The  diagnosis  is  further 
confirmed  by  the  presence  of  anesthetic  areas,  macules  char- 
acteristic of  leprosy,  tubercles,  loss  of  eyebrows,  and  thicken- 
ing of  the  ears  and  nose.  Manson^  mentions  that  "in  doubt- 
ful cases  further  assistance  may  sometimes  be  got  from  the 
fact  that  leprous  spots  rarely  perspire.  A  hypodermic  injec- 
tion of  pilocarpin  is  of  use  in  bringing  out  this  point."  Thick- 
ening of  the  nerves  in  association  with  some  of  the  other 
symptoms  mentioned  is  a  diagnostic  sign  of  great  importance. 
Likewise,  a  perforating  ulcer  of  the  foot,  with  other  leper 
symptoms,  is  also  of  much  value.  It  is  a  fact  worthy  of  men- 
tion that  natives  who  reside  in  countries  in  which  leprosy 
prevails,  although  they  have  no  medical  training,  are  often 
unusually  proficient  in  the  diagnosis  of  even  incipient  cases 
of  the  disease. 

Until  very  recently  the  prognosis  of  leprosy  was  most  dis- 
couraging. Occasionally  a  case  seemed  to  recover  spontane- 
ously or  was  attributed  to  some  treatment.  In  more  recent 
years  the  treatment  used  in  the  Philippines  has  resulted  in  the 
cure  of  at  least  10  per  cent,  of  the  cases  in  which  it  was  faith- 
fully carried  out,  and  under  similar  conditions  the  clinical 
disappearance  of  the  disease  in  at  least  25  per  cent,  of  the 
cases  seems  a  reasonable  figure.  It  may  he  stated  that  the 
faithful  use  of  treatment  as  recommended  zvill  arrest  the  progress 
of  the  disease  in  almost  every  case. 

TREATMENT. 
A  review  of  the  literature  shows  that  practically  the  entire 
pharmacopeia  has  been  called  into  requisition  in  an  attempt 
to  find  a  cure  for  the  disease.  A  trial  of  these  various  rem- 
edies shows  that  none  of  them  appear  to  be  of  much  value 
except   chaulmoogra  oil.     Of  all  the   remedies  used,   chaul- 


Fig.  1. — Case  of  lepros}'  in 
a  child  showing  inllltration, 
especially  in  cars,  lips,  and 
hands.  Leprons  nodnles  in 
the  left  arm.  Example  of 
tubercular  nodular  or  hyper- 
trophic leprosy. 


Fig.  3. — Typical  "main  en  grift''  in  leprosy, 


LEPROSY.  203 

moogra  oil  alone  has  stood  the  test  of  time.  Owing  to  the 
nauseating  effects  of  the  oil,  when  given  by  mouth,  it  was 
never  used  extensively.  A  preparation  of  the  oil  in  which  the 
emetic  principle  had  been  removed  was  tried,  but  this  appar- 
ently had  no  influence  on  leprosy.  Emulsions  of  different 
kinds  were  prepared.  Capsules  were  coated  with  various 
substances  so  as  to  permit  them  to  pass  through  the  stomach 
unaltered,  but  nausea  usually  followed  all  of  these  efforts.  It 
was  seldom  possible  to  find  a  patient  who  was  able  to  take 
the  prescribed  doses  by  mouth  for  a  period  longer  than  three 
months.  The  few  who  were  able  to  continue  usually  showed 
great  improvement,  and  occasionally  cures  were  reported. 
Enemas  of  chaulmoogra  oil  were  tried,  but  these  had  no 
apparent  influence  on  the  disease.  Chaulmoogra  oil  had  been 
given  hypodermically,  but  it  usually  failed  to  be  absorbed. 
To  overcome  this  difficulty  camphorated  oil  was  added  to  the 
chaulmoogra  resorcin  prescription  of  Unna,  and  this  made  the 
administration  of  chaulmoogra  oil  practicable.  The  prescrip- 
tion is  as  follows : 

Chaulmoogra  oil, 

Camphorated  oil aa  mils  60  (2  f5). 

Resorcin     grams     4   (61.7  gr.) . 

Mix  and  dissolve  with  the  aid  of  heat  on  a  water 
bath  and  then  filter. 

The  injections  are  usually  made  at  weekly  intervals  in 
ascending  doses.  The  initial  dose  is  1  mil  (16  m.),  and  this 
is  increased  to  the  point  of  tolerance.  Much  difference  exists 
among  the  cases  as  to  the  amount  of  the  mixture  which  they 
are  able  to  take.  In  some  cases  a  few  mils  produce  marked 
reactions  in  the  lesions,  accompanied  by  fever  and  cardiac 
distress.  Sometimes  it  is  better  to  reduce  the  amount  of  the 
dose  and  inject  at  more  frequent  intervals.  The  object  sought 
is  so  to  regulate  the  dose  as  to  prevent  reactions  of  too  vio- 
lent a  character.  Quicker  results  are  also  apparently  obtained 
when  it  is  possible  to  inject  the  mixture  into  large  leprous 
deposits  or  to  divide  the  dose  by  injecting-  it  into  a  number 
of  smaller  infiltrations.  Two  per  cent,  hot  sodium  bicarbonate 
tub  baths  are  prescribed  every  other  da}-.  Those  who  take 
prolonged  baths  regularly  seem  to  improve  more  rapidlv  than 
those  who  do  not.     This  treatment  should  be  given  over  a 


204  TROPICAL   DISEASES. 

period  of  at  least  two  years,  and  no  case  of  leprosy  should  be 
regarded  as  cured  until  it  has  been  continuously  negative, 
both  microscopically  and  clinically,  for  a  period  of  two  years. 
Recently  Vahram,  of  Paris,'*  has  recommended  the  intraven- 
ous injections  of  1;  mil  (16  w.)  doses  of  a  very  finely  sub- 
divided chaulmoogra  oil,  which  he  prepared  by  a  special 
process.  There  are  not  yet  sufficient  data  available  to  pass 
judgment  on  this  form  of  treatment. 

Prevention.  While  the  exact  mode  of  transmitting  leprosy 
is  not  known,  two  or  three  facts  stand  out  so  prominently  that 
the  course  in  attempting  to  prevent  its  spread  and  control 
seems  to  be  entirely  clear.  It  may  be  asserted  without  suc- 
cessful contradiction  that  no  cases  of  leprosy  occur  in  any 
community  in  which  there  has  not  been  a  previous  human 
case.  Unlike  tuberculosis,  public  opinion,  with  the  exception 
of  a  very  small  minority,  will  support  isolation  and  segrega- 
tion measures.  As  these  ofifer  the  only  hope  at  present  for  con- 
trolling or  eradicating  the  disease,  it  is  believed  to  be  the  duty 
of  medical  men  rigidly  to  advocate  this  policy,  and  to  take  all 
reasonable  steps  to  bring  it  about.  All  cases  of  leprosy, 
regardless  of  type,  in  which  it  is  possible  to  demonstrate  the 
leprosy  bacillus,  should  be  segregated  in  a  leper  colony.  Such 
lazaretto  should  be  made  comfortable  and  offer  every  reason- 
able facility  for  the  study  and  treatment  of  the  disease. 
Those  who  remain  negative,  both  clinically  and  microscopic- 
ally, for  a  continuous  period  of  two  years  should  be  released 
with  the  understanding  that  they  will  report  at  monthly  or 
quarterly  intervals  to  their  respective  health  officers  for 
examination.  The  conclusion  is  submitted  that  whatever  may 
be  the  views  of  well-informed  persons  with  regard  to  the  com- 
municability  of  leprosy,  and  however  widely  medical  men  may 
differ  upon  this  question,  yet  the  incontrovertible  fact  remains 
that  every  leper  is  a  source  of  danger  to  others,  and  at  least 
one  center  of  infection.  So  long  as  the  exact  mode  of  trans- 
mission is  not  known,  it  is  apparent  that  an  effort  to  control 
the  disease  without  eliminating  the  leper  as  a  center  of  infec- 
tion will  be  doomed  to  failure.  Prophylactic  medicine  should 
not  be  permitted  to  be  turned  by  a  few  sentimentalists  from 
its  march  to  a  goal  which  offers  the  prospect  of  the  eradica- 
tion of  this  plague  from  the  earth,  and  the  saving  of  many 


Fig.  4. — Case  of  macular 
and  nodular  leprosy  with 
marked  infiltration  of  the  face, 
before  treatment  with  chaul- 
moosra  oil   mixture. 


Fig.  5. — Same  case  as  above, 
after  hypodermic  treatment 
with  a  chaulmoogra  oil  mix- 
ture. 


MALARIAL   FEVER.  205 

innocent  victims  annually  from  contracting  this  most  loath- 
some disease. 

MALARIAL    FEVER. 

Of  the  numerous  synonyms  for  the  malarial  fevers  the  fol- 
lowing are  current:  Ague,  Chills  and  Fever,  Marsh  Fever, 
Remittent  Fever,  Intermittent  Fever,  Chagres  Fever,  Palud- 
ism,  Paludismo  (Spanish),  Palustre  (French),  Coast  Fever, 
and  Climatic  Fever. 

Malaria  is  a  term  used  to  designate  a  group  of  specific 
fevers  caused  by  protozoan  parasites  belonging  to  the  class 
Sporozoa.  The  definitive  host  is  the  mosquito,  and  the  inter- 
mediate host  is  man,  and  possibly  other  vertebrates.  There 
are  three  distinct  types  of  malarial  fever.  The  first  is  caused 
by  the  Plasmodium  malaricc,  the  second  by  the  Plasmodium 
vivax,  and  the  third  by  the  Laverania  malaricc. 

Malaria  is  a  disease  associated  with  the  remotest  antiquity. 
Hippocrates  recognized  the  existence  of  periodic  fevers,  and 
divided  them  into  the  quotidian,  tertian,  subtertian  and  quar- 
tan types.  Galen,  Celsus,  and  other  Roman  writers,  also  give 
accurate  descriptions  of  these  fevers.  Until  about  the  middle 
of  the  seventeenth  century  there  was  very  little  advance  in 
the  knowledge  of  malaria.  The  introduction  of  cinchona,  in 
1640,  enabled  Morton  and  Tort  to  separate  malarial  fevers 
from  other  febrile  diseases,  and  also  to  show  that  some  con- 
tinued and  remittent  fevers  belong  to  the  same  group  as  the 
intermittent  fevers.  Another  important  advance  was  the  de- 
scription of  the  characteristic  pigmentation  of  the  viscera  in 
malaria,  in  1847,  by  Meckel.  Virchow  confirmed  this  obser- 
vation. In  1854  Planer  noted  pigmented  cells  in  fresh  blood 
taken  from  the  finger  of  malarial  patients,  but  did  not  com- 
prehend their  true  nature.  The  parasitic  nature  of  malaria, 
which  had  been  suspected  for  many  years  by  Italian  observers, 
was  established  definitely  by  Laveran,  in  1880,  when  he 
described  the  eruption  of  the  long  mobile  filaments  from  the 
pigmented  cells  described  by  Meckel  and  Planer.  Laveran's 
observations  were  soon  confirmed  and  extended  by  Marchia- 
fava,  Celli,  Golgi,  Bignami  and  Bastianelli.  The  next  and 
most  important  advance  was  made  by  Ross,  in  1895,  when 
he    found    malarial    parasites    in    the    stomach    of    the    mos- 


206  TROPICAL   DISEASES. 

quito.  The  importance  of  the  discovery  that  malarial  fever 
is  conveyed  by  mosquitoes  was  probably  one  of  the  most  far- 
reaching-  that  has  ever  been  made  in  medicine.  The  control 
of  malaria  "has  now  been  definitely  placed  within  the  grasp  of 
the  sanitarian,  and  it  may  be  safely  predicted  that  it  is  pos- 
sible to  save  millions  in  lives,  sickness  and  treasure. 

As  intimated  above,  malarial  fevers  are  caused  by  the  para- 
sites Plasmodium  malaria;,  Plasmodium  vivax  and  Laverania 
malaricB.  These  parasites  may  be  spread  from  one  human 
being  to  another  through  the  intermediate  host,  the  mosquito, 
in  whose  bodies  they  undergo  development.  Infected  mos- 
quitoes are  capable  of  conveying  malarial  fever  to  healthy 
persons  in  non-malarial  climates.  This  experiment  was  actu- 
ally performed  on  Sir  Patrick  Hanson's  son,'^  when  a  mos- 
quito that  had  bitten  a  malarial  subject  in  Rome  was  per- 
mitted to  bite  him  later  in  London,  whereupon  he  developed 
a  typical  attack  of  the  disease. 

The  following  description  may  be  regarded  as  giving  the 
generic  features  common  to  the  three  different  classes  of 
parasites.     These  may,  again,  be  divided  into  three  phases. 

The  malarial  parasite,  like  all  true  parasites,  must  adapt 
itself  not  only  for  life  inside  its  host,  but  also  that  its  con- 
tinuance as  a  species  may  be  assured  during  the  passage  from 
one  host  to  another.  In  man,  it  exhibits  two  distinct  phases, 
an  intracorporeal  stage  and  an  extracorporeal  stage.  Clinical 
observation  and  analogy  indicate  that  there  is  yet  another 
phase  which  may  be  described  as  a  latent  phase,  whose  char- 
acter as  yet  can  only  be  conjectured. 

Each  species  of  the  malarial  parasite  has  its  special  or 
more  or  less  definite  intracorporeal  life  span  or  cycle  of 
twenty-four  hours,  forty-eight  hours  or  seventy-two  hours. 
Upon  examination  of  malarial  blood  toward  the  close  of  a 
cycle,  or  several  hours  before  the  occurrence  of  a  paroxysm 
of  the  characteristic  fever,  the  parasite  may  be  recognized  as 
a  pale  disc  of  protoplasm  occupying  a  larger  or  smaller  area 
within  certain  erythrocytes.  Throughout  this  pale  body  there 
are  numerous  intensely  black  or  reddish  black  particles.  This 
substance  has  been  referred  to  by  some  authors  as  melanin, 
and  by  others  as  hemozoin.  The  groups  of  black  particles 
concentrate  into  one  or  two  larger  and  more  or  less  central 


MALARIAL   FEVER.  207 

blocks,  around  which  the  pale  protoplasm  of  the  parasite 
arranges  itself  in  minute  segments,  which  finally  become  well- 
defined  spherules.  The  blood  corpuscle  is  then  destroyed,  and 
the  spherules,  none  of  which  contain  the  black  particles,  fall 
apart,  and,  with  the  black  particles,  become  free  in  the  blood- 
stream. The  leucocytes  soon  absorb  the  black  particles  and 
many  of  the  spherules.  A  certain  number  of  the  latter  escape 
the  leucocytes  and  attach  themselves  to  other  erythrocytes, 
which  they  enter.  In  the  interior  of  these  newly  infected  red 
corpuscles  the  young  parasites  exhibit  active  ameboid  move- 
ment, shooting  out  and  retracting  long  pseudopodia.  They 
grow  at  the  expense  of  the  hemoglobin,  so  that  the  erythro- 
cytes gradually  become  pale  through  the  loss  of  the  hemo- 
globin. As  the  parasites  grow  larger  the  ameboid  movement 
gradually  ceases. 

It  is  well  recognized  that  with  the  subsidence  of  the  acute 
clinical  symptoms,  the  malarial  parasite  may  disappear  from 
the  general  circulation.  This  is  not  always  necessarily  the 
result  of  the  administration  of  quinin.  It  may  happen  quite 
independently  of  this.  When  it  is  not  attributable  to  the 
effect  of  quinin,  the  disappearance  is,  as  a  rule,  only  tem- 
porary. Usually  after  an  interval  of  some  weeks  or  months 
the  parasite  reappears  in  the  general  circulation,  and  there  is 
a  renewal  of  the  clinical  symptoms.  The  location  of  the  para- 
site during  the  latent  period  is  unknown,  although  many 
believe  it  to  be  in  the  spleen,  while  others  suspect  the  marrow 
of  the  long  bones. 

If  the  micro-organism  propagates  so  actively  in  the  human 
body  that  it  has  no  opportunity  of  continuing  its  species,  by  pass- 
ing from  one  host  to  another,  we  are  forced  to  conclude  that 
some  provision  exists  in  the  economy  that  enables  the  parasite 
to  leave  and  enter  successive  hosts.  It  is  interesting,  then,  to 
study  the  manner  in  which  the  parasite  leaves  the  body,  what 
life  it  leads  outside  of  the  human  body,  and  how  it  re-enters 
the  human  body. 

The  flagellated  body  is  found  in  all  forms  of  malaria.  It 
is  an  octopus-like  structure,  with  long,  actively  moving-  arms. 
Although  it  is  composed  of  the  same  materials  (that  is,  trans- 
parent protoplasm  and  dark  granules),  yet  it  differs  in  many 
respects  from  the  ordinary  forms  of  the  parasite,  especially  in 


208  TROPICAL    DISEASES. 

that  it  is  not  intracorpuscular.  It  floats  free  in  the  liquor 
sanguinis.  It  has  usually  from  one  to  six  long  whip-like  arms, 
designated  as  flagella,  or,  more  correctly,  microgametes. 
Their  movements  are  so  vig'orous  that  they  frequently  double 
up  or  otherwise  disturb  temporarily  those  corpuscles  with 
which  they  chance  to  come  in  contact.  Occasionally  one  or 
more  of  these  flagella  break  away  and  swim  free  in  the  blood. 
If  kept  warm  they  may  remain  active  for  several  hours.  Spe- 
cial attention  should  be  drawn  to  the  fact  that  these  flagellated 
bodies  are  never  seen  in  the  freshly  prepared  specimen.  They 
come  into  view  only  after  a  slide  has  been  mounted  for  some 
time,  say  from  ten  to  thirty  minutes,  or  even  longer.  Upon 
the  examination  of  malarial  blood,  after  it  has  been  mounted 
as  a  wet  preparation,  it  is  not  unusual  to  observe  the  flagel- 
lated body.  Observation  has  shown  that  the  flagellated  bodies 
are  developed  during  a  particular  phase  of  the  intracorpus- 
cular parasite. 

The  bodies  known  as  crescentic  forms  are  not  present  in 
the  blood  at  the  commencement  of  the  malarial  infection,  or 
at  the  beginning  of  a  recrudescence  of  a  latent  infection. 
They  appear  in  the  blood  after  a  week  or  ten  days  of  acute 
clinical  symptoms.  At  first  they  are  few  and  difficult  to  find, 
but  gradually  they  become  numerous,  and  persist  for  days 
after  the  disappearance  of  other  forms  of  the  parasite.  They 
are  not  afifected  by  quinin.  They  may  disappear  from  the 
blood  in  a  week,  or  persist  for  six  weeks  or  longer.  At  times 
they  may  be  so  numerous  that  several  may  be  seen  in  every 
field  of  the  microscope.  Again,  they  are  so  scanty  that  many 
preparations  are  necessary  before  one  can  be  found,  and  at 
times  it  is  impossible  to  find  them.  The  crescent  bodies  and 
the  large  intracorpuscular  forms  are  sexual  in  their  functions. 
The  protoplasm  in  the  crescent  difi^ers  in  the  arrangements  of 
its  pigment,  and  the  characters  of  the  nucleus  are  revealed  by 
staining,  which  are  distinctive  of  the  male  and  the  female 
crescents,  respectively.  The  protoplasm  of  the  male  parasite 
stains  more  deeply  and  its  nucleus  is  larger  than  that  of  the 
female  parasite. 

If  a  number  of  crescent  bodies  are  kept  under  observation 
on  the  microscope  slide,  a  certain  number  of  them  will  be 
seen   slowly,   or   at   times   rapidly,   to   undergo   a  change   of 


.  *;) 


'T'^^ 


15 


16 


Fig.  6. — The  tertian  parasite. 


Norma  I  crijthroci/tc. 
3,  4,  5.    Intracellular  liyaline  forms. 

7.    Young  piymcntcd  intracellular  forms.    In  G  two  distmct  parasites  inhabit  the 
erythrocyte,  the  larger  one  being  actively  ameboid,  as  evidenced  by  the  long 
tentacular  process  trailing  from  the  main  body  of  the  organism.     This  ame- 
boid tendency  is  still  better  illustrated  in  7,  by  the  ribbon-like  design  formed 
by  the  parasite.     Note  the  delicacy  of  the  pigment  granules,  and  their  tend- 
ency toward  peripheral  arrangement  in  6,  7,   and  S. 
Later  developmental  staye  of  7.     In  7,  S,  and  9  enlargement  and  pallor  of  the  in- 
fected erythrocyte  become  conspicuous. 
Mature  intracellular  pigmented  parasite. 
10,  11,  12.    Segmenting  forms.     In  10  is  shown  the  early  stage  of  sporulation — the  de- 
velopment of  radial  striations  and  peripheral  indentations  coincidentally  with 
the  swarming  of  the  pigment  toward  the  center  of  the  parasite.     The  com- 
pletion of  this  process  is  illustrated  by  11  and  12. 
Large   stroUen   cxtracelhilar   form.      Note   the    coarse    fused    blocks    of   pigment. 

(Compare  size  with  that  of  normal  erythrocyte,  1.) 
Flagellate  form. 

Shrunken  and  fragmenting  cvtraccUiihir  farms. 
Tacuolation  of  an  extracellular  form. 


9. 


13. 

14. 
15. 
16. 


Note.— The  original  water-color  drawings  were  made  from  fresh  blood  specimens, 
a  Leitz  ^/jo-inch  oil-immersion  objective  and  4  ocular,  with  a  Zeiss  camera-lucida, 
being  used. 

(E.  F.  Faber,  fee.) 


"«....;»<>*' 


I'ij  (in  ^:i 


9 


:% 


Fig.  7. — The  quartan  parasite. 


1.  Normal  erythrocyte. 

2.  JntraceUular  hyaline  form. 

u.  yoinig  pigmented  intracellular  form.  Note  the  coarseness,  dark  color,  and  scanti- 
ness of  tlie  pigment  granules. 

4,  5,  6,  7.  Later  developmental  .'ita'jes  of  3.  Note  the  peripheral  distribution  of  the 
pigment  in  all  the  parasites  from  3  to  S.  (Compare  size  of  the  erythrocytes 
in  5,  6,  and  7  with  7,  8,  and  9,  Fig.  6.) 

8.  mature  intracellular  form.     Note  that  the  stroma  of  the  erythrocyte  is  no  longer 

demonstrable. 

9,  10,  11.     Seymentiny   formx.     In   9   are   shown    the   characteristic   radiating   linos  of 

pigment.      (Compare   with    10,    11,    and    12,    Fig.    G,    and    with    10,    11,    and    12, 
Fig.   8.) 

12.  Large  sicollen  eairacellnlur  form.     (Compare  with  in,   Fig.   6.) 

13.  Flayellatc  form.     (Compare  with  14,  Fig.  6.) 

14.  Tacuolation  of  an  extracellular  form. 

(E.  F.  Faber,  fee.) 


^N 


17 


Fig.  8. — The  estivo-autumnal  parasite. 

1.  'Normal  cryihroctjie. 

2,  3.    Young  hyaline  ring-forms. 

4,  5,  6.  Intracellular  lujaline  forms.  In  4  the  parasite  appears  as  an  irregularly 
shaped  disc  with  a  thinned-out  central  area.  In  5  and  6  its  ameboid  proper- 
ties are  obvious. 

7.  Young  pigmented  intracellular  form.     Note  the  extreme  delicacy  and  small  num- 

ber of  the  pigment  granules.     (Compare  with  6,  Fig.  6,  and  with  3,  Pig.  7.) 

8,  9.    Later  developmental  .itages  of  7. 
10,  11,  12.     Segmenting  forms. 

13,  14.     Crcseentic  forms  at  early  stages  of  their  development. 

15,  16,  17,  18,  19.     Cre.sccntic  forms.     In  15  and  19  a  distinct  "bib"  of  the  erythrocyte 

is  visible.     Vacuolation  of  a  crescent  is  shown  in  18,  and  polar  arrangement 

of  the  pigment  in  17. 

20.  Oval  form. 

21,  22.     Splwrieal  forms. 

23.  Flagellate  form. 

24.  Taeuolation  and  deformity  of  a  spherical  form. 

25.  Vacuolated  leucocyte  apparently  enclosing  a  du-arfcd  and  shrunken  crescent. 

26.  Remains  of  a  ■•shrunken  spherical  form. 


(E.  F.  Faber,  fee.) 


MALARIAL   FEVER.  209 

shape,  gradually  being  converted  into  flattened  crescents,  then 
into  oval  bodies,  and  then  into  spheres,  while  the  remains  of 
the  enclosing  blood  corpuscle  fall  to  pieces  or  dissolve. 

That  some  relationship  existed  between  the  mosquito  and 
malaria  has  long  been  entertained,  not  only  by  medical  men, 
but  also  by  inhalMtants  of  malarious  countries.  In  the  Roman 
Campagna,  for  instance,  the  peasants  have  believed  for  cen- 
turies that  the  disease  is  produced  by  the  bite  of  the  mosquito. 
Koch  pointed  out  that  the  natives  of  East  Africa,  who  inhabit 
the  highlands,  declare  that  when  they  visit  the  unhealthy  low- 
lands and  are  bitten  by  an  insect  which  is  presumably  the 
mosquito,  a  fever  results. 

In  1894,  and  again  in  1896,  Manson^  formulated  a  definite 
hypothesis  on  the  subject.  He  expressed  the  opinion  at  that 
time  that  the  parasite,  in  order  to  maintain  its  existence  as  a 
species,  must  pass  from  host  to  host.  In  other  words,  it  must 
at  times  have  an  extracorporeal  life,  He  concluded  that  the 
function  of  the  flagellum  lay  outside  of  the  human  body,  and 
that  the  flagellated  body  was  the  first  phase  of  the  extracor- 
poreal life  of  the  malarial  parasite.  As  the  parasite,  while  in 
the  circulation,  is  always  within  a  blood  corpuscle  and  is 
incapable  of  leaving  the  body  by  its  own  efiforts,  and,  so  far 
as  is  known,  is  not  excreted,  Manson  concluded  that  it  must 
be  removed  from  the  circulation  by  some  blood-sucking  insect. 
Manson  based  his  arguments  on  what  he  had  shown  to  be  the 
case  with  regard  to  the  Filaria  bancrofti,  and  reasoned  that, 
in  all  probability,  a  particular  type  of  mosquito  was  respon- 
sible. He  suggested  the  investigation  of  this  hypothesis  to 
Ross,  who  in  1897  was  able  to  offer  definite  proof  of  the  cor- 
rectness of  the  hypothesis."  A  gap  in  Ross's  observation 
was  filled  in  by  IMacGallum,  who  showed  by  observations 
of  a  malaria-like  parasite  in  birds  that  the  function  of  the 
filament  after  it  breaks  away  from  the  parent  sphere  or  flagel- 
lated body,  is  to  impregnate  the  granular  crescent-derived 
spheres  and  then  to  be  transformed  into  sharp-pointed  travel- 
ing vermicules. 

The  work  of  Ross  was  soon  confirmed  and  elaborated  by 
Daniels  and  by  Koch,  as  well  as  by  a  number  of  Italian 
observers.  Grassi  showed  that  several  species  belonging 
to  the  genus  Anopheles^  and  in  Italy  the  Anopheles  maciili- 

14 


210  TROPICAL   DISEASES. 

pennis,  are  the  special  mosquito  hosts  of  the  malarial  parasites 
of  man.  On  behalf  of  the  Colonial  Office  and  the  London 
School  of  Tropical  Medicine,  with  the  assistance  of  Dr.  Sam- 
bon  and  Dr.  Low,  Dr.  Manson  instituted  two  experiments 
which  resulted  in  silencing  all  the  objections  which  had  ap- 
peared against  the  theory.*^  Dr.  Sambon  and  Dr.  Low  lived 
for  the  three  malarial  months  of  1900  in  Ostia  in  the  malarial 
part  of  the  Roman  Campagna,  in  a  hut  from  which  mosquitoes 
were  excluded  by  wire  screens.  They  moved  about  freely  in 
the  neighborhood  during  the  day,  exposing  themselves  in  all 
weathers,  drank  the  water  of  the  place,  and  often  did  hard 
manual  work.  The  only  precaution  they  took  was  to  retire 
between  sunset  and  sunrise  to  their  mosquito-protected  house. 
They  took  no  quinin.  Their  neighbors,  the  Italian  peasants, 
were  attacked  by  malaria,  but  the  dwellers  in  the  mosquito- 
proof  house  enjoyed  immunity  from  the  disease.  While  this 
experiment  was  in  progress,  mosquitoes  fed  in  Rome  on 
patients  suffering  from  tertian  malaria  were  forwarded  in  suit- 
able cages  to  the  London  School  of  Tropical  Medicine,  and  on 
their  arrival  were  permitted  to  bite  the  son  of  Dr.  Manson 
and  Mr.  George  Warren.  Shortly  afterward  both  of  these 
gentlemen,  neither  of  whom  had  been  abroad  or  otherwise 
exposed  to  malarial  influence,  developed  characteristic  mala- 
rial fever,  and  malarial  parasites  were  found  in  abundance  in 
their  blood,  both  at  the  time  and  at  the  recurrence  of  the  fever 
from  which  they  subsequently  suffered.  The  mosquito  theory 
has,  therefore,  now  passed  from  the  region  of  conjecture  to 
that  of  fact. 

By  a  long  series  of  experiments  it  has  been  ascertained 
that  only  the  mosquitoes  which  belong  to  the  Anophelince 
group  are  capable  of  transmitting  an  infective  parasite  to  the 
human  host.  When  the  two  types  of  hyaline  and  granular 
crescent  bodies — that  is,  the  male  and  female — are  injested 
with  blood  of  man  by  Anopheles  mosquitoes,  they  soon  emit 
filaments  or  microgametes,  which  break  away  and  bore  into 
the  granular  spheres.  Soon  after  this  impregnation  takes 
place  an  elongated  oval  results,  which  gradually  assumes  a 
vermicular  form.  The  hemozoon  accumulates  on  the  posterior 
end,  while  the  anterior  end  becomes  pointed  and  hyaline.  On 
the   completion   of  these   changes   this   little   body   begins   to 


MALARIAL   FEVER.  211 

move  about,  first  slowly  and  then  rapidly.  This  traveling 
vermicule  is  technically  known  as  an  ookinete,  and  it  soon 
passes  into  a  white  or  a  red  blood  corpuscle.  Soon  afterward 
the  ookinete  penetrates  the  wall  of  the  mosquito's  stomach, 
where  it  may  be  found  thirty-six  hours  after  it  has  been 
injested  by  the  mosquito.  During  the  next  few  days  the  para- 
site increases  rapidly,  acquires  a  well-defined  capsule,  and 
coon  protrudes  on  the  surface  of  the  insect's  stomach.  Dur- 
ing this  period  important  changes  take  place  in  the  interior 
of  the  parasite,  and  the  term  oocyst  is  now  applied.  The 
nucleus  and  protoplasm  divide  into  a  number  of  spherical 
daughter  cells,  around  which,  attached  by  one  end,  like  the 
spines  on  a  porcupine,  a  vast  number  of  minute,  slender, 
spindle-shaped,  nucleated  bodies  are  ultimately  formed.  At  a 
later  stage  the  spherules  disappear  and  leave  the  spindles,  the 
so-called  sporozoites,  loose  in  the  capsule,  which  is  now 
packed  to  the  bursting  point.  In  about  a  week — and  the 
period  depends  much  on  the  atmospheric  temperature — the 
capsule  ruptures  and  collapses,  and  discharges  its  contents 
into  the  body  cavity  of  the  mosquito. 

From  the  body  cavity  of  the  mosquito  the  sporozoites  pass 
by  the  way  of  the  blood  to  the  salivary  gland  of  the  mosquito, 
which  lies  on  each  side  of  the  forepart  of  the  thorax  of  the 
insect.  These  glands  communicate  with  the  base  of  the  mos- 
quito's proboscis  by  means  of  a  long  duct.  When  the  mos- 
quito bites  man  these  sporozoites  are  injected  during  the  act 
of  biting,  and  eight  or  ten  days  later  the  malarial  parasite  mav 
be  found  in  the  circulating  blood  of  the  infected  man. 

So  far  as  is  known  at  present  the  malarial  fevers  can  be 
conveyed  to  man  only  by  the  means  of  mosquitoes.  How- 
ever, there  are  instances  which  arise  which  make  it  difficult  to 
understand  how  mosquitoes  and  man  alone  can  be  respon- 
sible. It  has  been  frequently  reported  that  in  certain  areas 
of  the  world  which  are  entirely  uninhabited  bv  man.  a  malarial 
infection  may  be  contracted  by  a  visit  to  such  areas.  It  has 
also  been  pointed  out  that  malaria  frequently  occurs  where 
public  works  are  undertaken  which  are  attended  with  dis- 
turbances of  the  soil,  as  in  railroad  building,  canal  work, 
harbor  works,  etc.  Faulty  observation  probably  explains 
many  of  these  instances.     Mosauitoes  which  have  had  access 


212  TROPICAL   DISEASES. 

to  man  are  often  present  without  actually  being  observed. 
Other  instances  are  usually  explained  on  the  basis  that  there 
is  a  possibility  of  another  host  than  man  for  the  malarial  para- 
site. Parasites  closely  resembling  human  malarial  organisms 
have  been  found  in  bats,  and  also  in  monkeys.  Another 
explanation  submitted  is  that  malarial  parasites  may  be  trans- 
mitted from  one  generation  of  mosquitoes  to  another  through 
the  means  of  their  eg'gs.  There  is  the  support  of  analogy  for 
this  hypothesis.  Babesia  hovis,  which  gives  rise  to  Texas  fever 
in  cattle,  and  Babesia  canis,  which  causes  malignant  jaundice 
in  dogs,  are  both  said  to  be  transmitted  through  the  means 
of  eggs.  In  general,  however,  it  may  be  stated  that  most 
observers  are  of  the  opinion  that  under  natural  conditions 
malaria  can  be  acquired  by  man  only  through  the  bite  of  a 
mosquito,  and  that  a  mosquito  can  obtain  its  infection  only 
by  biting  an  infected  human  being. 

For  the  microscopic  examination  of  the  blood,  several 
preparations,  as  a  rule,  should  be  made,  the  blood  being 
obtained  by  gentle  compression  of  the  finger-tip  or  the  lobe 
of  the  ear,  and  a  puncture  then  made  with  a  needle  that  is 
triangular  on  cross  section.  Antiseptic  precautions,  of  course, 
should  be  observed.  A  droplet  of  blood  should  be  collected 
on  a  cover-glass,  care  being  taken  that  the  glass  does  not  come 
in  contact  with  the  skin.  The  cover-glass  should  then  be 
dropped  upon  the  glass  slide.  Pressure  to  cause  the  blood  to 
spread  out  should  not  be  used.  If  the  glasses  have  been  well 
cleaned,  the  blood  will  at  once  run  out  in  a  fine  film,  showing 
the  flat  surfaces  of  the  corpuscles,  lying  edge  to  edge.  After 
waiting  a  few  moments  for  the  blood  to  spread  out  it  is  well 
to  ring  the  preparation  with  vaseline.  This  will  stop  all 
movement,  evaporation  and  overcompression  of  the  corpus- 
cles, and  will  greatly  facilitate  examination.  Accuracy  can 
be  acquired  only  by  practice,  and  those  examining  blood 
should  learn  the  art  from  one  who  has  had  considerable 
experience.  Further  details  of  the  microscopic  technic  and 
staining  methods  can  be  obtained  from  various  laboratory 
manuals. 

The  different  species  of  malarial  parasites  have  been  classi- 
fied in  accordance  with  (a)  the  duration  of  their  respective  life 
circles  inside  the  human  body,  (&)  their  morphologic  charac- 


MALARIAL    FEVER.  213 

ters,  (c)  the  clinical  phenomena  to  which  they  give  rise,  and 
(d)  the  results  of  inoculation  experiments. 

In  the  first  place,  malaria  may  be  divided  into  the  benign 
and  the  malignant  type.  Morphologically,  the  benign  para- 
sites do  not  form  crescent  bodies,  and  the  most  important 
malignant  parasites  do  form  crescents.  The  gamete  of  the 
benign  parasite  is  a  sphere  or  a  disc,  and  the  gamete  of  the 
malignant  parasite  is  a  crescent.  Clinically  the  benign  para- 
site does  not  give  rise  to  pernicious  attacks,  while  the  malig- 
nant parasite  usually  does.  The  benign  parasites  are  of  two 
kinds :  (a)  the  quartan  parasite,  having  a  cycle  of  seventy- 
two  hours,  causing  a  recurring  fever  every  three  days,  so- 
called  quartan  fever;  (b)  the  tertian  parasite,  which  has  a 
cycle  of  forty-eight  hours,  and  causes  recurring  fever  every 
two  days,  so-called  tertian  fever.  The  malignant  parasite  has 
three  forms,  and,  perhaps,  more.  The  pigmented  parasite 
causes  so-called  subtertian  fever  of  forty-eight  or  approxi- 
mately forty-eight  hours'  cycle.  Another  pigmented  parasite, 
often  called  the  pigmented  quotidian,  has  a  twenty-four  hours' 
cycle,  and  is  referred  to  by  some  authors  as  double  tertian. 

Formerly  classification  was  based  entirely  upon  clinical 
phenomena,  and  referred  to  as  quotidian,  tertian  and  quartan 
intermittent  fever  or  ague,  and  remittent  fever.  But  since  it 
has  been  found  that  remittent  fevers  are  produced  by  either 
quartan,  tertian,  subtertian,  or  by  quotidian  parasites,  it  is 
believed  that  the  classification  given  above  is  more  desirable. 
It  is  quite  likely  that  further  study  of  the  disease  will  bring 
about  a  more  satisfactory  classification  than  exists  at  the 
present  time. 

Typical  attacks  of  intermittent  malarial  fever,  and  most 
of  them  are  typical  in  persons  infected  for  the  first  time,  con- 
sist of  a  series  of  phenomena  which  recur  at  definite  intervals. 
Each  attack  consists  of  a  chill,  a  period  of  fever,  and  a  perio-d 
of  sweating ;  and  these  are  succeeded  by  an  interval  of 
apyrexia.  There  is  much  variation  in  the  duration  and  inten- 
sity of  the  diftercnt  stages.  As  a  rule,  there  is  a  certain  pro- 
portionate relationship.  Often  the  more  pronounced  the  cliill, 
the  higher  the  fever,  and  the  more  profuse  the  sweating".  The 
expression  "ague"  is  applied  only  to  intermittent  fever  witli 
which  there  is  a  pronounced  chill. 


214  TROPICAL   DISEASES. 

The  geographical  distribution  of  the  malarial  fevers  is 
widespread.  The  tertian  is  probably  the  most  common  form, 
and  occurs  in  temperate  and  tropical  latitudes  alike.  The 
pernicious  forms  of  the  fever  are  rarely  found  outside  of  the 
tropical  belt.  Generally  speaking,  malaria  is  most  virulent 
in  the  region  of  the  Equator,  and  decreases  numerically  and 
in  virulence  as  the  distance  from  the  Equator  increases.  The 
malarious  area  may  be  said  to  lie  between  63  degrees  north 
latitude  and  35  degrees  south  latitude.  Many  countries  that 
suffered  severely  from  the  disease  in  the  past  now  are  ap- 
parently becoming  free  of  malaria.  For  instance,  except  in 
limited  areas,  the  disease  is  not  known  to  occur  at  present  in 
England,  Holland,  France  and  Germany.  In  former  times 
malaria  prevailed  in  all  of  these  countries  to  a  very  consider- 
able extent.  In  the  United  States  the  northern  line  of  the 
disease  is  gradually  receding.  Some  years  ago  malaria  was 
very  common  in  Wisconsin,  Minnesota,  Iowa  and  other  north- 
ern States.  At  present  there  is  practically  no  malaria  in  those 
regions.  It  is  rather  rare  to  find  a  case  north  of  Mason  and 
Dixon's  line.  On  the  other  hand,  malaria  is  appearing  in 
many  regions  in  which  it  has  not  occurred  heretofore.  This 
is  due  to  improved  means  of  travel,  through  persons  in  the 
infective  stage  taking  up  residence  in  places  in  which  Ano- 
pheles mosquitoes  occur.  Instances  of  this  kind  were  very 
common  in  the  Philippines,  and  it  was  often  noted  that  when 
troops  that  had  been  stationed  in  malarious  districts  were 
transferred  to  other  villages,  provinces  or  islands,  in  which 
malaria  had  not  formerly  prevailed,  the  disease  soon  appeared 
among  the  inhabitants.  Sugar  plantations,  public  works,  and 
other  places  where  malaria  prevailed  often  recruited  laborers 
from  islands  that  were  free  from  malaria,  and  later  when  these 
laborers  returned  to  the  islands  they  caused  outbreaks  of 
malaria.  In  accordance  with  a  recent  survey  made  by  Trask^ 
based  on  reports  received  from  State  and  city  health  officials, 
the  distribution  of  malaria  in  the  United  States  was  included 
in  the  following  areas :  "The  large  endemic  area  covers  the 
whole  southeastern  portion  of  the  United  States,  having  for 
its  southern  boundary  the  Gulf  of  Mexico ;  for  its  western 
boundary,  a  line  drawn  from  Eagle  Pass,  on  the  Rio  Grande, 
to  Leavenworth,  Kan. ;  for  its  eastern  boundary  the  Atlantic 


MALARIAL   FEVER.  215 

seaboard;  its  northern  boundary,  a  line  drawn  from  Leaven- 
worth, Kan.,  eastward  some  distance  north  of  the  Ohio  River 
and  extending  to  the  Atlantic  on  a  line  with  the  northern 
boundary  of  Maryland.  Of  the  two  smaller  endemic  areas, 
one  includes  a  section  of  the  northern  part  of  New  Jersey, 
southeastern  New  York,  Connecticut,  Rhode  Island,  and  part 
of  the  State  of  Massachusetts.  The  third  recognized  endemic 
area  is  in  California,  and  includes  the  Sacramento  and  San 
Joaquin  Valleys,  which  occupy  a  large  portion  of  the  central 
part  of  the  State.  It  is  probable  that  the  New  England 
endemic  area  actually  extends  southward  to  the  large  south- 
ern area  of  which  it  is  in  reality  a  part."  These  surveys 
showed  that  there  was  one  large  and  two  smaller  areas. 

The  mosquito  malaria  theory,  which  is  now  thoroughly 
established,  furnishes  the  key  to  the  etiologic  problem. 
Whatever  favors  the  presence  and  increase  of  malaria-bear- 
ing mosquitoes  also  tends  to  increase  the  incidence  of  malaria, 
provided  that  there  are  human  beings  in  the  vicinity  whose 
blood  harbors  the  malarial  parasites.  The  disease  is  caused 
by  the  Plasmodium  malaricu  of  Laveran,  by  the  Plasmodium 
vivax,  and  the  Laverania  malaria:.  These  parasites  are  always 
found  in  the  blood  or  organs  of  the  person  suffering  from  the 
disease,  and  can  be  injected  into  healthy  persons,  in  which 
they  cause  typical  fevers,  which  occur  in  different  stages  and 
correspond  to  the  life  cycle  of  the  particular  parasite  which 
has  been  injected.  There  are  three  factors  necessary  for  the 
production  of  malarial  fever:  the  blood  parasite,  the  mos- 
quito and  man. 

Malarial  fever  is  found  in  the  northern  hemisphere  from 
the  Arctic  Circle  to  the  Equator.  In  the  southern  hemi- 
sphere its  distribution  is  perhaps  equally  great,  although  not 
yet  so  well  proved.  The  disease  is  not  uniformly  distributed 
throughout  this  vast  area.  It  occurs  in  limited  endemic  foci, 
and,  as  pointed  out  above,  the  disease  tends  to  become  more 
virulent  as  the  Equator  is  approached. 

The  relationship  between  temperature  and  mosquitoes  is 
very  definite.  Practically  no  cases  of  malaria  occur  after 
sufficient  frosts  have  taken  place  effectuallv  to  kill  all  mos- 
quitoes. New  cases  do  not  occur  again  until  weather  condi- 
tions favor  the  breeding  of  mosquitoes.     There  are  certain 


216  TROPICAL   DISEASES. 

countries,  although  in  the  tropical  belt,  in  which  malaria  does 
not  occur.  For  instance,  the  Fiji  Islands  and  Barbados  are 
typical  examples.  A  careful  mosquito  survey  made  in  both 
these  countries  shows  a  complete  absence  of  the  Anopheles 
mosquito.  Rainfall  and  conditions  of  moisture  apparently 
have  no  influence  on  the  disease,  except  in  so  far  as  they  pro- 
mote the  breeding  of  mosquitoes.  Likewise,  winds  and  at- 
mospheric diffusion  are  only  important  in  the  etiology  of  the 
disease,  in  so  far  as  they  may  be  the  means  of  either  prevent- 
ing the  flight  of  mosquitoes,  or  assisting  in  the  distribution 
of  the  infected  insects. 

In  times  past  it  was  often  thought  that  certain  trees,  as, 
for  instance,  eucalyptus  trees,  were  protection  against  malaria. 
It  is  more  than  likely  that  this  apparent  protection  may  have 
been  due  to  the  drying  influences  on  the  soil  which  eucalyptus 
trees  possess  owing  to  the  large  amount  of  water  which  they 
withdraw;  The  odor  of  the  trees  may  also  have  deterred  mos- 
quitoes from  coming  near.  It  is  also  possible  that  they  may 
have  given  protection  by  forming  wind-breaks,  and  thus  inter- 
fered with  the  flight  of  mosquitoes  from  swamps  or  other 
insect-breeding  grounds. 

The  time  of  the  day  in  relation  to  infection  also  conforms 
very  closely  to  the  habits  of  the  mosquito.  Anopheles  usually 
fly  only  between  sunset  and  sunrise,  and  persons  can  ordi- 
narily go  into  malarious  districts  during  the  daylight  hours 
without  any  great  danger  of  contracting  the  infection. 

It  has  been  explained  by  Koch  and  others  that  the  ap- 
parent immunity  which  exists  among  Negroes, .  Melanesians 
and  other  dark-skinned  races  living  in  highly  malarious  coun- 
tries, is  in  all  probability  due  to  the  resistance  they  have 
acquired  during  the  constant  attacks  they  suffered  in  child- 
hood. It  has  been  observed  that  the  percentage  of  infected 
children  gradually  becomes  smaller  as  their  age  increases. 

When  a  malarial  infection  occurs,  the  body  is  invaded  by 
protozoal  parasites  which  grow  and  increase  at  the  expense 
of  the  red  cells  of  the  blood,  and  upon  these  essential  premises 
the  pathologic  changes  incident  to  the  disease  are  based.  Two 
toxins  have  been  isolated — pyrogenetic  toxin  and  hemolysin. 
Erythrocytes  are  found  in  all  the  circulatory  organs,  and  are 
generally  within  the  blood-vessels.     In  the  spleen  and  in  th? 


MALARIAL   FEVER.  217 

bone-marrow,  however,  they  come  into  intimate  relationship 
with  the  parenchyma.  It  would  seem  that,  as  the  parasites 
are  distributed  by  the  erythrocytes,  they  should  be  found  in 
all  of  the  organs.  But  this  condition  does  not  usually  follow, 
especially  in  pernicious  infections.  When  it  does  not  occur 
the  parasites  probably  damage  the  red  blood-corpuscles,  and 
through  the  toxins  set  free,  the  endothelium  of  the  vessels  is 
damaged,  especially  that  of  the  capillaries,  and  blocking  of 
the  blood-stream  occurs,  which  prevents  even  distribution. 
Apparently  the  damage  done  to  the  erythrocytes  by  the  quar- 
tan parasites  is  not  severe  enough  to  cause  their  stagnation 
in  the  capillaries.  Therefore,  they  are  more  evenly  dis- 
tributed than  the  other  types.  Tertian  parasites  cause  the 
erythrocytes  to  undergo  swelling,  degeneration  and  decolori- 
zation.  The  subtertian  parasites  also  seriously  affect  the  red 
cells,  and  make  them  smaller  and  darker.  Subtertian  para- 
sites are  seldom  found  in  the  peripheral  circulation  in  the 
sporulating  stage.  The  pigment  which  remains  after  the  red 
corpuscle  is  destroyed  may  be  found  in  the  peripheral  blood 
in  a  free  state,  and  in  the  mononuclear  leucocytes.  Hem- 
olysin also  escapes  from  the  sporulating  parasite,  damages 
the  erythrocyte  and  causes  the  appearance  of  another  pig- 
ment, yellowish  in  color,  called  hemosiderin.  This  is  de- 
posited in  the  parenchyma  cells  of  the  organs,  especially  in 
the  liver.  The  damage  done  to  the  parenchyma  is  but  slowly 
repaired,  and  considerable  time  elapses  before  permanent 
recovery  takes  place.  In  the  case  of  the  subtertian  parasite, 
serious  local  damage  may  be  done  to  the  brain,  the  intestine, 
the  pancreas,  or  other  organs  in  which  the  parasites  may  mass 
themselves  within  the  capillaries. 

There  are  two  main  distinctions  to  be  made  in  the  path- 
ology of  malaria.  First,  that  of  acute  malaria;  and,  second, 
that  of  chronic  malaria.  In  acute  malaria  the  eft'ects  are  pro- 
duced by  each  of  the  three  parasites,  of  which  the  subtertian 
is  liable  seriously  to  damage  important  organs.  Chronic 
malaria  is  encountered  in  a  condition  called  malarial  cachexia, 
which  manifests  itself  in  the  form  of  acute  cachexia,  chronic 
cachexia,  and  cachexia  with  amyloidosis. 

Rosenau  and  his  collaborators  proved  the  poisonous  prop- 
erties of  the  pyretogenous  toxin.     It  is  not  definitely  known 


218  TROPICAL   DISEASES. 

whether  this  poison  has  deleterious  influences  upon  the  tis- 
sues of  the  organs. 

Iron  is  excreted  through  the  urine  in  increased  quantities. 
This  increase  does  not  appear,  however,  until  several  day;5 
after  the  actual  attack  is  over.  The  chlorides  are  diminished. 
The  phosphates  are  increased.  The  sulphates  are  higher  than 
normal,  but  during  the  actual  attack  they  are  lower  than 
normal. 

Iron  is  also  excreted  in  considerable  quantities  through 
the  feces.  The  sweat  of  malarial  patients  has  a  peculiar  odor 
and  is  toxic  to  rabbits.  Hemozoin  is  the  black  pig'ment 
formed  from  the  hemoglobin  by  the  malarial  parasites  while 
they  are  in  the  red  blood-cells.  This  pigment  is  later  dis- 
tributed to  the  different  organs,  and  accumulates,  as  a  rule, 
in  large  quantities  in  the  liver  and  spleen.  Hemosiderin  is 
the  yellow  pigment  usually  found  in  the  parenchyma  cells  of 
the  liver,  spleen,  kidney,  bone-marrow,  and  endothelium  of 
capillaries. 

The  malarial  parasites  in  the  blood  produce  changes  in  the 
red  cells  by  their  own  action  and  through  their  toxins.  They 
are  the  most  important  feature  in  the  pathology  of  the 
blood.  Ross^o  estimates  that  the  average  person  weighing 
150  pounds  (68  Kg.)  possesses  25,000,000,000,000  erythro- 
cytes. In  a  severe  infection  he  estimates  that  12  per  cent., 
or  3,000,000,000,000  corpuscles,  are  affected.  It  also  has  been 
quite  definitely  demonstrated  that  large  numbers  of  parasites 
may  exist  in  the  body  and  go  through  their  life  cycle  in  the 
spleen  without  causing  noticeable  clinical  symptoms.  This 
type  of  disease  is  usually  referred  to  as  latent  malaria. 

The  most  characteristic  pathologic  signs  of  malaria  at 
autopsy  are  slatish-  or  bluish-  black  pigmentation,  which 
affects  mostly  the  spleen,  liver,  brain,  and  sometimes  the 
intestinal  mucosa.  The  spleen  is  always  enlarged  and  usually 
quite  soft.  The  liver  is  enlarged  and  congested.  Pigmenta- 
tion is  most  pronounced  in  those  cases  that  have  died  after 
protracted  infection.  In  the  brain  sometimes  the  capillaries 
are  found  to  be  actually  plugged  with  masses  of  erythro- 
cytes which  contain  parasites,  together  with  phagocytic  cells. 
Occasionally  free  parasites  also  are  found  in  the  blood.  A 
similar  condition  is  sometimes  found  in  the  capillaries  of  the 


MALARIAL    FEVER.  219 

mucosa  of  the  intestine.  Some  authors  report  total  necrosis 
in  the  liver,  and  there  are  nearly  always  parasites  in  the 
capillaries.  The  spleen  is  practically  always  heavily  infested 
with  parasites,  which  may  readily  be  demonstrated  in  stained 
microscopic  sections.  The  Plasmodium  z'izvx  seldom  causes 
death,  but,  as  a  rule,  there  are  other  lesions  due  to  intercur- 
rent disease. 

In  undertaking  a  description  of  the  symptomatology  of 
malarial  fever  it  should  be  kept  in  mind  that  malaria  is  due 
to  three  distinct  parasites,  namely,  Plasmodium  malaricc,  Plas- 
modium vivax  and  Laverania  malaricc.  These  parasites  give 
rise  to  three  clinical  entities,  namely,  quartan  malarial  fever, 
tertian  malarial  fever  and  subtertian  malarial  fever,  but  there 
are  a  number  of  subdivisions  of  these  different  varieties.  The 
quartan  and  tertian  parasites  have  their  whole  life  history  in 
the  circulating-  blood,  and  while  the  tertian  sporulating  forms 
may  be  found  in  the  internal  organs,  spleen  or  other  internal 
organs,  yet  they  do  not  accumulate  or  produce  special  effects 
in  those  organs.  The  subtertian  parasites  sporulate  almost 
entirely  in  the  internal  organs,  and  it  is  this  sporulation  in  an 
organ  which  gives  rise  to  the  special  clinical  features  which 
have  been  described  as  the  pernicious  types  of  malarial  fever. 
The  particular  variety  of  fever  will  depend  upon  whether  the 
parasite  is  localized  in  the  cerebrospinal  nervous  system,  in 
the  gastro-intestinal  mucosa,  or  in  the  pancreas,  the  heart,  the 
lungs,  or  the  liver. 

The  Quartan  Fevers.  Quartan  fevers  depend  upon  the 
Plasmodium  malaricc  which  has  been  introduced  into  the  blood 
by  the  Anopheles  mosquito,  and  the  clinical  course  will 
depend  upon  whether  the  parasites  are  approximately  the 
same  age  or  whether  they  have  been  introduced  into  the  body 
on  different  days.  If  malarial  organisms  of  about  the  same 
age  have  been  introduced  into  the  blood,  they  will  give  rise 
to  typical  quartan  malarial  fever,  which  has  an  interval  of 
seventy-two  hours  between  the  paroxysms.  This  corresponds 
to  the  period  required  by  the  merozo'ite  to  reach  the  fully 
developed  schizont.  This  type  of  fever  is  known  as  simple 
quartan.  If  the  parasites  have  been  introduced  on  dift'erent 
days,  and  also  are  perhaps  of  different  ages,  the  patient  will 
develop  fever  on  two  successive  days  and  be  free  on  the  third 


220  TROPICAL    DISEASES. 

day.  Such  a  fever  will  be  called  a  double  quartan.  From  the 
foregoing-  it  is  evident  that  many  combinations  are  possible, 
depending  upon  the  intervals  of  introduction  and  the  age  of 
the  parasites. 

Simple  Quartan  Fever.  The  incubation  period  of  fever 
due  to  this  parasite  has  not  been  definitely  determined. 
Celli,  by  experiment,  came  to  the  conclusion  that  perhaps 
the  incubation  period  was  several  months  or  more.  By  ex- 
perimental inoculation  of  blood,  other  Italian  workers  esti- 
mated that  the  maximum  incubation  period  was  eighteen 
days,  and  the  minimum  eleven  days. 

The  Fever  Stage.  As  a  rule,  several  hours  before  the  rise 
of  temperature  occurs,  the  patient  may  complain  of  dizziness, 
weakness,  malaise,  headache,  and  sometimes  nausea  and 
vomiting.  If  the  blood  should  be  examined  during  this 
period  the  parasites  would  be  found  to  be  schizonts.  At  the 
expiration  of  several  hours  the  definite  attack  begins,  which 
may  be  divided  into  three  stages :  first,  the  chill}^ ;  second,  the 
fever;  and,  third,  the  sweating. 

The  Cold  Stage.  A  chilly  sensation  is  felt  in  the  legs,  arms 
or  back.  This  increases  until  actual  shivering  sets  in.  The 
rigors  are  well  marked  and  characteristic,  and  it  is  not  infre- 
quent that  the  patient  will  actually  shake  the  bed.  The  teeth 
chatter,  the  lips  become  blue,  the  arms  and  legs  cold,  and 
goose-skin  may  be  present.  The  cold  stage  is  by  far  the  most 
uncomfortable.  The  internal  temperature  rises  rapidly,  and 
congestion  of  the  internal  organs  usually  takes  place.  The 
temperature  may  vary  from  100°  to  105°  F.  (37.7°  to  40.5° 
C).  The  chill)^  stage  usually  does  not  last  more  than  thirty 
minutes,  although  it  may  be  much  shorter  or  even  longer. 

The  Hot  Stage.  The  shivering  gradually  ceases  and  the 
patient  begins  to  feel  warmer  and  more  comfortable,  although 
there  are  waves  of  hot  and  cold  sensations  that  pass  through 
the  body.  The  patient  begins  to  throw  off  the  bed-clothes. 
The  skin  feels  hot  and  dry,  and  the  frequenc}^  of  the  pulse  and 
respirations  increases.  Vomiting  and  diarrhea  may  occur, 
and  a  red  flushing,  especially  of  the  face  and  neck,  frequently 
may  be  observed.  The  temperature  remains  at  its  maximum 
until  the  latter  part  of  this  stage,  which  usually  lasts  from 
three  to  four  hours, 


MALARIAL   FEVER.  221 

The  Sweating  Stage.  It  may  be  noted  that  perspiration 
begins  to  gather  about  the  forehead  and  gradually  appears  all 
over  the  body.  The  patient  begins  to  feel  more  comfortable. 
The  temperature  falls  rapidly  and  the  pulse  rate  declines. 
Very  often  the  patient  falls  into  a  deep  sleep,  and  the  symp- 
toms generally  disappear. 

The  Interval.  If  the  patient  has  gone  to  sleep,  he  usually 
awakens  feeling  quite  refreshed,  although  weak,  and  goes 
about  his  ordinary  work  during  the  entire  two  days'  interval. 
Examination  of  the  blood  at  this  stage  shows  that  there  may 
be  leucopenia,  and  also  developing  parasites.  At  the  end  of 
the  seventy-two  hours  the  fever  again  rises,  and  there  is  a 
repetition  of  practically  all  the  symptoms  described  above. 
There  are,  of  course,  many  irregularities  in  the  appearance  of 
the  symptoms,  but  the  description  given  corresponds  more  or 
less  to  the  typical  case. 

Quartan  fever  is  usually  regarded  as  having  a  great  ten- 
dency to  relapse  and  to  reappear  even  at  intervals  of  years, 
if  it  has  not  been  adequately  treated.  Pernicious  symptoms 
seldom  appear.  If  the  disease  remains  untreated  the  fever 
gradually  disappears,  but  recurs  at  times.  Complete  spon- 
taneous cure  is  regarded  as  being  rare. 

Double  Quartan  Fever.  In  this  form  of  malaria  there  is 
an  attack  on  two  successive  days,  and  an  interval  of  freedom 
from  fever  of  twenty-four  hours.  Otherwise,  the  symptoms 
are  much  the  same  as  those  described  above. 

Triple  Quartan  Fever.  This  form  is  due  to  triple  infec- 
tion, and  there  are  daily  paroxysms  of  the  kind  described 
above,  the  interval  lasting  only  a  few  hours. 

Tertian  Fevers ;  The  Simple  Tertian.  This  fever  recurs 
every  forty-eight  hours,  with  apyrexial  intervals  of  a  day. 
Prodromata  may  or  may  not  occur.  In  some  instances  they 
are  quite  characteristic,  and  take  the  form  of  pain  in  the  head 
and  back,  especially  in  the  bones  of  the  limbs,  particularly  in 
the  joints.  These  pains  are  often  mistaken  for  rheumatism. 
There  is  a  feeling  of  lassitude  and  illness.  On  the  day  suc- 
ceeding the  foregoing  symptoms  the  patient  may  feel  quite 
well,  and  the  day  following  the  symptoms  may  begin  to  recur. 
If  treatment  should  take  place  in  this  stage,  fever  may  never 
occur.     If  untreated,  after  dizziness,  nausea  or  vomiting,  and 


222  TROPICAL   DISEASES. 

some  rise  in  temperature,  the  patient  suddenly  becomes  very 
cold  and  shivers,  and  the  symptoms  resemble  those  described 
for  quartan  malarial  fever,  except  that  they  are  not  so  severe. 
In  less  than  half  an  hour  the  warm  stage  begins.  Soon  the 
patient  feels  burning  hot,  the  skin  is  flushed  and  dry,  the  eyes 
are  injected,  the  pulse  is  quick  and  often  dicrotic,  and  the 
pains  in  the  head  and  back  increase.  Not  infrequently  in  the 
white  race  there  is  a  sallow  or  slightly  yellowish  tinge.  In 
the  native  races  this  can  only  be  observed  in  the  conjunctiva. 
The  spleen  is  enlarged  and  tender.  The  temperature  begins 
to  rise  before  the  chill,  and  may  reach  105°  F.  (40.5°  C).  The 
whole  attack  usually  lasts  from  ten  to  twelve  hours,  and  gen- 
erally begins  in  the  morning,  but  may  take  place  any  time  of 
day. 

Double  Tertian  Fever.  When  malarial  organisms  mature 
on  separate  days  there  may  be  paroxysms  every  day.  This 
type  of  fever  is  referred  to  as  the  double  tertian.  The  symp- 
toms are  similar  to  those  before  described. 

If  tertian  malaria  remains  untreated  it  has  a  tendency 
toward  spontaneous  cure,  but  relapses  may  occur  from  time 
to  time.  The  anemia  of  tertian  fevers  apparently  yields  more 
readily  to  treatment,  or  even  to  self-cure  than  that  due  to 
other  malarial  parasites. 

Subtertian  Fever.  In  subtertian  fever,  although  it  is  a 
tertian  fever,  the  attacks  are  due  to  the  Lavcrania  malaricc,  and 
are  very  much  more  prolonged  than  those  due  to  the  tertian 
parasites.  At  least  six  different  types  of  subtertian  fever  are 
described  by  various  authors. 

Simple  Subtertian  Fever.  According  to  Marchiafava  and 
Bignami  the  incubation  period,  when  transmitted  by  the  mos- 
quito, is  from  nine  to  ten  days ;  and  longer  when  acquired 
by  experimental  mosquito  infection.  The  chilly  stage  of  the 
fever  may  be  entirely  absent,  although  there  are  instances  in 
which  it  is  severe.  Very  often  the  attack  begins  with  a  warm 
stage,  accompanied  by  severe  pains  in  the  limbs,  back  and 
head,  with  vomiting  and  diarrhea.  The  skin  is  usually  flushed 
and  dry,  and  sometimes  somewhat  jaundiced.  The  sweating 
stage  is  usually  well  marked.  The  spleen,  as  well  as  the  liver, 
is  tender.  The  hourly  temperature  chart  is  of  great  diag- 
nostic value.     The  invasion  usually  begins  with  a  tempera- 


MALARIAL   FEVER.  223 

ture  of  104°  to  105°  F.  (40°  to  40.5°  C),  with  hourly  oscilla- 
tions of  one  degree  Fahrenheit.  Usually  the  oscillation,  which 
immediately  precedes  the  crisis,  is  larger,  and  is  often  referred 
to  as  the  pseudocrisis.  It  is  after  this  precrisis  that  the  tem- 
perature reaches  its  highest  point,  and  then  falls  very  sud- 
denly. In  brief,  the  symptoms  largely  correspond  to  an 
irregular  type  of  tertian  fever. 

Double  Subtertian  Fever.  This  is  a  daily  fever,  caused  by 
two  invasions  of  the  lavcvania  malarial  parasite.  The  symp- 
toms resemble  very  closely  those  described  before.  Other 
forms  of  subtertian  fever  are  described  as  irregular  subtertian 
fever,  remittent  subtertian  fever,  in  which  the  temperature 
during  the  interval  does  not  reach  normal,  and  also  a  bilious 
remittent  fever.  This  derives  its  name  from  the  fact  that  it 
is  associated  with  jaundice,  much  vomit  of  bile,  and  usually 
a  bilious  diarrhea.  It  is  due  to  the  fact  that  there  has  been 
great  erythrocyte  destruction  with  consequent  bile  produc- 
tion. Another  variety  is  described  under  the  head  of  per- 
nicious subtertian  fever.  The  subtertian  parasite  may  pass 
its  life  history  in  the  capillaries  of  some  particular  organ, 
and  in  that  event  the  clinical  symptoms  are  more  or  less 
localized.  However,  there  may  be  pernicious  malaria  due  to 
large  numbers  of  parasites  in  the  general  circulation.  This 
latter  type  may  be  divided  into  the  algid  pernicious,  the 
diaphoretic  pernicious,  the  hemorrhagic  pernicious,  and  the 
scarlatinaform  pernicious.  The  type  with  local  symptoms 
may  be  divided  into  the  cerebrospinal,  the  gastro-intestinal, 
the  cardiac  and  the  pulmonar}^ 

The  Algid  Form.  The  patient  usually  is  in  extreme  col- 
lapse, and  may  present  many  of  the  symptoms  of  cholera. 
The  cheeks  ar?  sunken,  the  lips  are  cyanotic,  the  nails  are 
blue,  the  pulse  is  small  and  soft,  frequently  becoming  thready 
and  imperceptible,  the  skin  is  cold  and  clammy,  and  the 
respiration  is  labored.  This  is  a  very  fatal  form  of  pernicious 
malaria,  and  usually  the  patient  dies  in  a  few  hours. 

The  Diaphoretic  Type.  In  this  fever  the  sweating  of  the 
third  stage  is  profuse.  It  often  happens  that  not  only  the  bed 
is  saturated,  but  a  pool  of  water  may  be  found  on  the  floor. 
The  patient  soon  becomes  completely  exhausted,  and  collapse 
may  occur  at  any  time. 


224  TROPICAL   DISEASES. 

The  Hemorrhagic  Pernicious  Type.  This  type  of  the  dis- 
ease is  rare,  and  is  characterized  by  hemorrhages  of  the  skin 
and  the  mucous  membrane  of  the  nose,  bronchi,  intestines, 
stomach  and  g-enerative  organs.  These  hemorrhages  occur 
during-  the  fever  stage.  This  disease  rapidly  produces  serious 
anemia,  ending  in  coma,  delirium,  convulsions  and  death. 

The  Scarlatinaform  Type.  This  is  characterized  by  a  scar- 
latinaform  rash  which  appears  all  over  the  body,  with  desqua- 
mation. If  not  treated,  it  usually  leads  to  the  typhoid  state, 
in  which  the  patient  succumbs. 

The  Cerebrospinal  Type.  Very  often  symptoms  of  hemi- 
plegia are  present.  In  malarious  districts  in  cases  of  apparent 
apoplexy  blood  examinations  should  invariably  be  made  for 
malarial  parasites.  The  fever  in  this  type  of  the  disease  may 
be  comatose  in  character.  Usually  the  patient  comes  under 
the  observation  of  the  medical  man  in  an  unconscious  condi- 
tion, with  no  paralysis  and  no  alteration  in  the  reflex.  The 
pupils  may  be  markedly  contracted  and  resemble  those  in 
opium-poisoning.  In  cases  in  which  the  prognosis  is  grave, 
the  patient  becomes  colder  and  colder  until  death  takes  place. 
Hemorrhages  are  usually  found  in  the  skin  and  the  retina; 
albumin  and  casts  in  the  urine.  There  are  many  variations 
of  the  comatose  type.  They  may  take  the  form  of  delirium, 
tetanic  or  eclamptic  convulsions,  hemiplegia,  aphasia,  amau- 
rotic symptoms.  Bulbar  symptoms  may  also  occur.  Some- 
times ataxic  symptoms  are  very  pronounced.  In  brief,  there 
may  be  nervous  symptoms  which  resemble  any  of  the  well- 
known  nervous  diseases  due  to  pressure  in  the  brain. 

G  astro -intestinal  Types.  Some  forms  of  pernicious  malarial 
fever  closely  resemble  cholera,  and  may  be  accompanied  by 
marked  vomiting  and  diarrhea,  with  abdominal  pains,  sub- 
normal temperature,  and  other  symptoms  characteristic  of 
cholera.  An  examination  of  the  blood  will  usually  reveal  the 
parasites.  The  temperature  does  not  remain  subnormal  for 
a  prolonged  i:)eriod  of  time.  Sometimes  the  symptoms  resem- 
ble those  of  severe  dysentery  or  hemorrhagic  pancreatitis,  or 
even  those  of  pneumonia  or  pleurisy ;  the  latter  when  there  is 
stagnation  of  the  parasites  in  the  capillaries  of  the  lungs  or 
of  the  pleura. 


MALARIAL   FEVER.  225 

Chronic  Malaria.  Chronic  malaria  may  result  from  any  of 
the  three  types  of  malarial  parasites,  but,  as  a  rule,  chronic 
malaria  is  caused  by  the  Laverania  malaricc.  Under  this  head 
is  also  usually  included  the  clinical  entity  known  as  malarial 
cachexia.  The  symptoms  of  chronic  malaria  are  repeated 
attacks  of  slight  fever,  which  may  pass  unnoticed.  There  is 
enlargement  of  the  spleen  and  liver,  and  pigmentation  of  the 
skin  and  mucosa.  Frequently  there  is  pigmentation  in  the 
tongue,  which  makes  this  condition  more  readily  recognizable 
in  the  dark  races.  The  pale  jaundice  condition  of  the  skin  in 
persons  who  have  lived  in  malarious  districts  over  long 
periods  of  time  is  most  characteristic.  Briefly,  chronic  malaria 
resembles  a  mild  attack  of  the  benign  fevers  which  has  been 
described  above. 

In  malarial  cachexia  the  intervals  between  the  fever  are 
very  long-,  and  may  be  of  several  weeks'  duration.  During 
these  intervals  it  is  almost  impossible  to  find  the  malarial 
parasite.  When  the  mild  febrile  attacks  occur  the  parasite 
can  usually  be  found  in  the  blood.  This  condition  is  fre- 
quently mistaken  for  uncinariasis.  Chronic  malaria  and 
malarial  cachexia  usually  result  when  there  has  been  insuffi- 
cient treatment,  or  when  no  treatment  has  been  carried  out. 

Relapses.  Malarial  relapses  in  those  who  have  suffered 
from  the  disease  are  frequent.  They  often  occur  in  persons 
who  may  have  been  free  from  the  disease  for  months,  and 
even  for  years.  They  are  specially  common  among  those  who 
have  had  malaria  in  the  tro])ics  and  then  go  to  a  cooler  cli- 
mate. Soon  after  being  subjected  to  a  lower  temperature, 
typical  attacks  of  malaria  may  occur.  This  is  often  noticed 
in  the  tropics  when  infected  persons,  who  have  been  living  in 
malarious  lowlands  for  a  long  period,  go  to  the  mountains 
where  the  temperature  is  low.  In  this  type  of  attack  reinfec- 
tion in  all  probability  has  not  taken  place.  In  addition  to  the 
relapses  which  occur  upon  change  of  climate,  relapses  in  cases 
that  have  not  been  adequately  treated  are  also  frequent. 
These  occur  from  twenty  days  up  to  a  number  of  months 
after  the  original  attack  has  occurred. 

Reinfection,  Persons  who  are  constantly  exposed  to  mos- 
quitoes that  have  bitten  cases  of  malaria  naturally  have  many 
opportunities  to  become  reinfected,  and  there  is  much  evi- 
ls 


226  TROPICAL   DISEASES. 

dence  that  this  actually  takes  place.  Previous  attacks  appar- 
ently give  no  immunity  to  fresh  infections,  or  at  least  very 
little  protection,  especially  if  these  infections  happen  to  be 
with  parasites  of  a  different  type  from  those  from  which  the 
original  infection  took  place. 

Complications.  Complications  in  malaria  are  rather  com- 
mon. Typhoid  fever,  for  instance,  has  been  frequently  asso- 
ciated with  malaria,  and  has  caused  great  literature  on  this 
problem  to  appear.  For  instance,  during  the  time  of  the 
Spanish-American  War,  it  was  contended  by  one  set  of  phy- 
sicians that  the  large  sick  rate  which  occurred  in  Cuba  was 
due  to  malarial  fever  with  typhoid  symptoms,  whereas  an- 
other group  of  physicians  contended  that  it  was  an  anomalous 
form  of  typhoid  fever.  It  is  more  than  likely  that  in  many 
of  these  instances  there  was  an  infection  with  typhoid  as  well 
as  with  the  malarial  parasite.  Briefly,  malaria  and  typhoid 
may  exist  in  the  same  individual,  but  it  is  not  believed  that 
this  occurs  very  often.  With  modern  laboratory  aids  it  is  not 
likely  that  any  great  difficulty  will  exist  in  making  the  proper 
distinction.  Dysentery,  both  the  bacillary  and  the  amebic, 
being  a  common  tropical  disease,  frequently  is  associated  with 
malarial  fever.  There  is  still  considerable  dispute  as  to 
whether  there  is  a  true  malarial  pneumonia,  or  whether  the 
pneumonia,  which  is  frequently  associated  with  malaria,  is 
due  to  the  regular  pneumonia  organisms  which,  perhaps,  are 
able  to  invade  the  human  host,  on  account  of  the  lowered 
state  of  resistance  incident  to  attacks  of  malarial  fever. 
Nephritis  is  commonly  associated  with  tertian  and  subtertian 
fevers,  and  is  probably  caused  by  the  irritation  to  the  kidney 
by  the  malarial  toxins. 

Sequelae.  The  sequelae  of  malarial  fever  are  numerous,  and 
may  occur  in  the  nervous  system,  the  sense  organs,  the  blood, 
the  liver  and  the  spleen.  In  the  nervous  symptoms,  insanity, 
melancholia  or  other  psychoses  are  not  infrequent.  Neuritis 
of  malarial  origin  is  very  common,  and  often  is  associated 
with  distressing  symptoms.  Neuralgia  is  a  frequent  sequela, 
and  may  persist  for  years.  It  is  considered  doubtful  whether 
tinnitus  aurium,  vertigo,  deafness,  amaurosis  and  loss  of  taste 
are  actually  due  to  malaria,  or  whether  they  are  due  to  over- 
doses of  quinin.     Cirrhosis  of  the  liver,  according  to  many 


MALARIAL   FEVER.  227 

authors,,  may  follow  a  prolonged  attack  of  malaria.  Charac- 
teristic enlargement  of  the  spleen  is  very  frequent.  Persistent 
anemias,  which  do  not  yield  to  treatment,  frequently  follow 
malarial  fever. 

The  diagnosis  of  malarial  fever  in  reality  depends  upon 
demonstrating  by  the  aid  of  the  microscope  the  malarial 
parasite  in  the  blood.  The  clinical  symptoms,  however, 
in  most  cases  of  malaria  are  so  characteristic  that  a  clinical 
diagnosis  usually  can  be  made.  However,  no  diagnosis 
should  be  recorded  as  malaria  unless  it  has  been  definitely 
confirmed  by  microscopic  methods.  The  fact  that  malarial 
parasites  cannot  always  be  found  in  the  peripheral  blood, 
however,  does  not  necessarily  show  that  the  diagnosis 
of  malaria  can  be  dismissed.  Splenic  puncture  will  often 
yield  blood  specimens  in  which  the  malarial  parasite  can  be 
demonstrated.  The  periodicity  which  occurs  in  the  fever 
curve  in  the  various  forms  of  malarial  fever  is  most  charac- 
teristic, and  usually  will  lead  to  diagnosis.  However,  marked 
temperature  intermissions  or  remissions  due  to  accumulations 
of  pus,  especially  when  these  occur  in  the  liver,  must  be  care- 
fully excluded.  It  is  often  stated  that  a  fever  that  is  not 
influenced  by  four  days  of  active  quinin  treatment  may  be 
dismissed  as  malaria.  This  is  usually  true  with  regard  to 
fevers  due  to  the  tertian  and  the  quartan  parasites,  but  may 
not  be  true  in  fevers  caused  by  the  subtertian  parasites.  It  is 
not  an  infrequent  experience  to  find  a  fever  unaffected  bv 
quinin,  and  yet  to  find  malarial  parasites  of  the  subtertian 
variety  in  the  peripheral  blood.  In  malarial  cachexia  a  care- 
ful clinical  examination,  especially  hourly  temperature  charts, 
may  be  of  more  value  in  arriving  at  a  correct  diagnosis  than 
blood  examinations.  Repeated  examinations  of  the  blood, 
however,  will  often  result  in  demonstrating  the  malarial  para- 
site in  the  erythrocytes,  or  finding  hemozoin  in  the  white 
corpuscles.  The  differentiation  of  bilious  remittent  fever  and 
yellow  fever  at  times  causes  considerable  difficulty.  When 
due  to  malaria,  albuminuria  is  not  common,  and  is  seldom 
ever  so  marked  as  in  yellow  fever.  The  temperature  in 
malaria  may  remain  continually  high,  while  in  yellow  fever 
there  is  a  sharp  remission  at  the  end  of  three  or  four  days. 
There  is  more  vomiting  in  yellow  fever.     The  pulse  does  not 


228  TROPICAL   DISEASES. 

become  slow  in  malarial  fever.  Cerebrospinal  meningitis  at 
times  offers  difficulties,  but  the  rigidity  of  the  muscles  of  the 
neck  usually  leads  to  blood  examinations  which  make  it  pos- 
sible to  exclude  malaria.  With  the  aid  of  the  microscope 
there  is  usually  no  difficulty  in  separating  malarial  fever  from 
many  of  the  diseases  which  cause  chills  and  fever,  as,  for 
instance,  urethral  fever,  the  passage  of  gall-stones,  pyelitis, 
lymphangitis,  especially  that  associated  with  elephantiasis 
and  filaria,  Mediterranean  fever,  kala-azar,  ulcerative  endo- 
carditis, typhoid  fever,  abscess  of  the  liver,  rapidly  growing 
sarcoma,  visceral  syphilis,  and  many  obscure  and  ill-defined 
conditions. 

The  prognosis  of  malarial  fever  is  closely  associated 
with  climate,  race,  age,  sex  and  type  of  parasite  caus- 
ing the  infection,  and  the  presence  or  absence  of  organic 
complications.  An  idiosyncrasy  against  quinin  is  also  at 
times  an  important  factor.  With  regard  to  climate,  it  is  well 
known  that  recovery  does  not  take  place  so  readily  when  the 
stimulating  effects  of  cool  air  are  not  available.  In  persons 
from  the  temperate  zone,  who  later  contract  malarial  fever  in 
tropical  countries,  the  prognosis  is  not  as  good  as  in  those 
who  have  passed  their  childhood  in  malarial  districts.  Dur- 
ing childhood  a  certain  amount  of  immunity  is  apparently 
acquired  by  the  infections  which  usually  take  place.  Infec- 
tion with  tertian  and  quartan  parasites  affords  a  much  better 
prognosis  than  infection  with  the  subtertian.  The  pernicious 
forms  and  latent  malarias,  as  well  as  malarial  cachexia,  do 
not  always  furnish  a  favorable  prog'nosis,  yet  if  an  accurate 
diagnosis  is  made  reasonably  early  and  experienced  treatment 
is  available,  there  is  considerable  hope  that  complete  elimina- 
tion of  the  infection  can  be  brought  about.  Persons  who  are 
unable  to  stand  usual  doses  of  quinin  should  not  risk  resi- 
dence in  malarious  countries.  The  mortality  among  Euro- 
peans in  places  where  pernicious  forms  of  malaria  prevail  is 
usually  high.  It  is  stated  that  the  mortality  among  natives 
of  such  districts  is  low,  but  this  view  may  be  subject  to  cor- 
rection under  more  careful  observation. 

Malarial  fever  is  no  doubt  frequently  confounded  with 
ankylostomiasis,  kala-azar,  typhoid  fever,  and  similar  condi- 
tions which  cause  chills  and  fever. 


MALARIAL   FEVER.  229 

TREATMENT. 

It  is  generally  stated  that  the  use  of  quinin  in  malaria 
is  one  of  the  few  instances  of  a  true  specific  which  occurs  in 
medicine.  This  statement  seems  to  be  true  in  so  far  as  the 
great  majority  of  the  cases  are  concerned,  but  there  can  be 
little  doubt  that  there  are  many  cases  of  malarial  infection  in 
which  the  use  of  quinin,  given  under  the  most  favorable  cir- 
cumstances, fails  completely  to  eliminate  the  infection  from 
the  human  system.  Recent  developments  in  the  study  of 
malaria  show  that  the  treatment  of  the  disease  by  quinin,  as 
ordinarily  administered,  is  most  ineffective.  Many  thousands 
of  individuals  who  are  regarded  as  cured  of  malarial  fever 
after  a  few  doses  of  quinin,  still  have  latent  infections  which 
at  any  time  may  prove  detrimental  to  the  individual,  and  act 
as  reservoirs  from  which  malarial  infection  is  distributed  far 
and  wide.  The  greatest  difference  of  opinion  prevails  among 
medical  men  of  large  experience  as  to  the  best  salt  of  quinin 
to  employ,  the  dose,  and  the  intervals  at  which  it  should  be 
administered.  Many  of  these  differences,  in  all  probability, 
arise  from  the  fact  that  some  persons  apparently  do  not 
absorb  quinin  through  the  intestinal  tract,  but  when  admin- 
istered hypodermically  a  favorable  result  is  obtained.  It  often 
happens  that  an  individual  will  not  absorb  the  drug  through 
either  of  these  channels,  when  the  intravenous  method  often 
furnishes  a  solution.  Many  salts  of  quinin  have  been  advo- 
cated from  time  to  time,  but  sulphate  of  quinin  seems  to  be 
more  generally  used  than  any  other  salt,  and  when  adminis- 
tered, so  far  as  the  oral  route  is  concerned,  in  an  intelligent 
manner,  probably  gives  as  good  average  results  as  rnanv  of 
the  other  salts  or  the  fanciful  preparations  which  have  been 
placed  upon  the  market.  When  quinin  is  administered  bv 
mouth  it  probably  gives  the  best  results  in  the  liquid  form, 
but  owing  to  the  bitterness  of  the  solution  it  is  practically 
impossible,  to  give  quinin  in  this  way.  For  administration 
per  Oram  the  two  methods  of  choice  usually  narrow  down  to 
pills  and  capsules.  Pills  very  often  have  a  sugar  or  other 
coating  which  is  not  readily  dissolved  by  the  gastric  secre- 
tions, and  are  passed  through  the  system  without  an^^  absorp- 
tion having  taken  place.     If  it  is  necessary  to  use  pills,  an 


230  TROPICAL   DISEASES. 

investigation  should  alwa3^s  be  made  to  ascertain  whether 
they  are  being  absorbed.  Probably  one  of  the  most  safe  and 
satisfactory  methods  of  giving  quinin  is  by  the  means  of 
capsules.  If  there  is  any  doubt  as  to  their  absorption,  small 
doses  of  water  acidulated  with  hydrochloric  acid  may  be 
administered  immediately  after  the  quinin  has  been  taken. 

There  have  been  many  reasons  advanced  for  the  adminis- 
tration of  quinin  at  certain  intervals.  The  most  universal 
custom  has  been  to  administer  the  drug  three  times  a  day 
after  meals.  Recently  OchsnerU  drew  attention  to  his  experi- 
ences in  the  treatment  of  malaria  in  Mexico,  for  which  he 
claims  unusually  satisfactory  results  by  the  administration  of 
2  grains  (0.13  Gm.)  of  quinin  at  two-hour  intervals,  fol- 
lowed by  withdrawal  of  the  drug  for  five  days,  and  then  a 
repetition  of  the  dose.  (For  complete  details  of  this  treat- 
ment see  method  of  administration  below.)  This  mode  of 
administration  is  based  on  the  theory  that  quinin  will  kill 
adult  malarial  organisms,  but  will  not  kill  sporozoites.  Con- 
sequently, if  quinin  is  given  continuously  the  development 
of  the  sporozoites  is  retarded,  but  they  will  grow  into  adult 
forms  as  soon  as  the  quinin  is  withdrawn.  By  allowing  a 
suitable  interval  between  the  quinin  treatments  an  oppor- 
tunity is  afiforded  for  the  sporozoites  to  develop  into  adults, 
and  they  can  then  be  effectively  killed  by  the  subsequent 
administration  of  quinin. 

It  has  been  customary  in  the  past  to  administer  to  robust 
adults  10  grains  (0.65  Gm.)  of  quinin  in  two  5-grain  (0.32 
Gm.)  capsules,  given  three  times  daily,  or  a  total  dose  of  30 
grains  (1.9  Gm.)  every  twenty-four  hours.  Work  recently 
undertaken  in  the  Southern  States  by  Bass  in  the  treatment 
of  malaria  indicates  that  among  persons  who  are  chronic  car- 
riers a  dose  of  10  grains  (0.65  Gm.)  per  day  is  insufficient 
properly  to  sterilize  the  blood.  In  order  to  make  treatment 
efifective  administration  of  quinin  should  be  followed  at  sub- 
sequent intervals  by  careful  examinations  of  the  blood  to 
ascertain  whether  any  parasites  are  present,  and  quinin 
should  be  repeated  in  all  cases  where  they  are  found. 

Until  quite  recently  many  of  the  older  physicians  recom- 
mended the  use  of  Warburg's  tincture  after  quinin  given  in 
the  ordinary  form  had  failed,  but  it  is  now  considered  to  be 


MALARIAL  FEVER.  "  231 

of  doubtful  value,  and  not  nearly  so  efificient  in  obstinate  cases 
as  the  administration  of  quinin  by  the  intravenous,  or  even 
the  hypodermic,  method.  Quinin  in  large  doses  is  a  cardiac 
depressant,  and  this  fact  must  be  borne  in  mind  when  admin- 
istering the  drug  to  the  old  and  the  feeble,  especially  by 
intravenous  or  intramuscular  injections.  Quinin  acts  as  a 
stimulant  to  the  nervous  system,  and  is  said  to  cause  an 
increased  flow  of  blood  to  the  brain.  In  the  tissues  it  is 
partly  destroyed  by  oxidation,  and  usually  the  whole  quantity 
administered  can  be  found  in  the  urine.  Excretion  takes  place 
through  the  kidneys  in  the  form  of  quinin  dihydroxyl. 
When  given  in  large  doses  it  causes  cerebral  congestion, 
which  produces  buzzing  in  the  ears,  headache  and  deafness, 
due  to  congestion  of  the  middle  ear.  These  symptoms  can 
usually  be  greatly  relieved  by  bromids,  or  by  ergot.  Quinin 
eruptions  occur  from  time  to  time  in  the  form  of  erythema- 
tous, or  even  papular,  vesicular,  and  urticarial  eruptions.  The 
belief  is  very  generally  held  that  the  administration  of  quinin 
in  some  persons  may  cause  hemoglobinuria.  Amblyopia  is 
another  untoward  result,  and  appears  to  be  due  to  the  con- 
tractions caused  in  the  retinal  arteries,  which  may  even  go  on 
to  degeneration  of  the  retinal  ganglion,  and  cause  serious 
permanent  eye  disturbances.  Quinin  is  a  stimulant  to  the 
uterus,  and  its  use  in  pregnancy  must  be  carefully  guarded. 
In  mild  quartan  and  tertian  fevers  there  is  little  doubt  that 
excellent  results  are  obtained  by  administering  quinin  four 
hours  before  the  attack.  This  corresponds  to  the  period  of 
the  sporulation  of  the  parasite.  As  stated  before,  however, 
the  administration  of  the  drug  three  times  a  day,  without 
fine  theoretical  considerations  as  to  its  effect  upon  para- 
sitic life,  apparently  produces  results  which  are  just  as 
successful  as  any  other  kinds  of  administration  which  have 
been  suggested. 

Method  of  Administration.  In  the  past  it  has  been  cus- 
tomary to  treat  all  ordinary  cases  of  quartan  and  tertian  fevers 
with  10  grains  (0.65  Gm.)  of  quinin  sulphate,  given  in  5- 
grain  (0.325  Gm.)  capsules,  three  times  a  day  wnth  meals. 
Much  has  been  written  about  the  desirability  of  employing 
quinin  salts  that  are  readily  soluble  in  water,  but  in  actual 
experience  quinin  sulphate  appears  to  be  as  effective  when 


232  TROPICAL   DISEASES. 

given  by  mouth  as  salts,  which  are  more  soluble.  Quinin 
bisulphate  is  probably  the  most  soluble,  and  the  best  drug-  to 
use,  and  it  may  be  administered  in  the  same  doses  as  the  sul- 
phate. Ochsner'si2  method  consists  in  an  exclusive  diet  of 
hot  soup  for  ten  days.  On  the  evening  of  the  first  day  2 
ounces  (60  mils)  of  castor  oil  are  administered.  At  6  a.m.  on 
the  second  day  he  begins  by  giving  a  2-grain  (0.13  Gm.)  cap- 
sule of  quinin,  preferably  bisulphate,  with  the  cover  of  the 
capsule  removed,  with  Y^  pint  (236  mils)  of  hot  water,  every 
two  hours  night  and  day  for  30  doses.  He  lays  great  stress 
upon  not  missing  a  single  dose,  owing  to  the  importance  of 
keeping  fresh  quinin  constantly  in  the  blood.  This  is  followed 
for  six  nights  and  five  days  with  a  pill  of  %o  grain  (0.00130 
Gm.)  of  arsenous  acid  with  Yi  pint  (236  mils)  of  hot  water  at 
6,  9,  12,  3  and  6  o'clock.  At  the  end  of  this  period  castor  oil 
is  given  as  on  the  first  day.  At  6  a.m.,  following  the  sixth 
night,  he  again  repeats  the  2-grain  (0.13  Gm.)  doses  of  quinin 
at  two-hour  intervals  until  30  doses  have  been  taken.  This 
is  followed  by  general  tonics  and  wholesome  nourishing  food. 
In  pernicious  forms  of  malaria  where  the  prompt  exhibition  of 
quinin  is  essential  to  save  life,  the  bihydrochlorid  should  be 
given  intravenously  in  5-grain  (0.324  Gm.)  doses.  The  technic 
should  be  the  same  as  that  employed  in  the  administration  of 
salvarsan. 

If  the  case  is  particularly  aggravated,  this  treatment  should 
be  repeated  at  intervals  of  several  hours,  and  the  dose  increased 
if  the  circumstances  seem  to  demand  it.  In  very  serious  cases 
as  much  as  40  grains  (2.6  Gms.)  of  quinin  may  be  given 
intravenously  during  twenty-four  hours.  In  ordinary  cases 
of  malaria,  and  especially  the  chronic  type  which  do  not 
respond  readily  to  treatment,  better  results  frequently  can  be 
obtained  by  administering,  in  connection  with  the  quinin,  3 
mils  (48.6  m.)  of  fluidextract  of  ergot.  The  action  of  the  ergot 
in  this  connection  has  been  explained  on  the  basis  that  ergot 
being  a  stimulant  of  non-striped  muscular  tissue  causes  con- 
tractions in  the  spleen  and  small  blocked  blood-vessels  which 
result  in  forcing  malarial  parasites  into  the  general  circula- 
tion where  they  can  readily  be  reached  by  the  quinin.  This 
explanation  seems  rather  doubtful,  but  it  has  been  frequently 
demonstrated  that  ergot  is  efficient  in  connection  with  quinin 


MALARIAL   FEVER.  233 

in  certain  types  of  malaria.  In  latent  or  chronic  malaria  good 
results  may  be  obtained,  after  quinin  has  failed,  with  10- 
grain  intravenous  doses  of  salvarsan  or  neosalvarsan.  In 
chronic  malaria,  or  cases  in  which  there  has  been  extreme 
prostration,  or  in  which  quinin  does  not  seem  to  be  effective, 
Fowler's  solution  in  ascending  doses  often  brings  about 
prompt  improvement.  It  is  well  to  begin  with  3-drop  (0.18 
mil)  doses  in  water  three  times  a  day,  with  an  increase  in  the 
total  dose  for  the  day  of  1  drop  until  the  point  of  tolerance  is 
reached.  This  usually  happens  before  8  drops  (0.50  mil)  per 
dose,  or  a  total  of  24  drops  (1.50  mils)  for  the  day,  is  being 
taken.  It  is  then  well  to  reduce  the  dose  by  2  drops  (0.12  mil). 
That  is  to  say,  if  8-drop  (0.50  mil)  doses  are  being  given  with 
a  total  of  24  drops  (1.50  mils)  per  day,  6-drop  (0.36  mil)  doses 
should  be  given  with  a  total  of  18  drops  (1.12  mils)  per  day. 
As  a  rule,  hypodermic  injections  of  quinin  are  not  to  be  rec- 
ommended. Much  better  results  are  obtained,  and  the  danger 
from  abscess  formation  is  greatly  reduced,  if  intramuscular 
injections  are  used  instead.  For  this  purpose  the  bihydro- 
chlorid  is  the  best  salt  to  employ.  Baccelli's  formula,  which 
is  frequently  used  for  this  purpose,  consists  of  10  grams 
(154.3  grs.)  of  bihydrochlorid  of  quinin  and  0.075  grams 
(1.1  grs.)  of  ordinary  salt  dissolved  in  10  grams  (154.3 
grs.)  of  water.  One-tenth  of  this  mixture  is  used  for  each 
injection.  Great  precaution  must  be  observed  to  ensure 
the  sterility  of  the  mixture.  Injections  of  quinin  are  fre- 
quently associated  with  abscess  formation,  and  tliis  must  be 
rigidly  guarded  against.  In  malarious  countries,  in  which 
intramuscular  injections  of  quinin  may  be  frequently  em- 
ployed, it  is  well  to  keep  a  quinin  solution  in  sterilized  tubes 
of  the  proper  dosage.  A  preparation  suitable  for  this  purpose 
can  be  made  with  10  grams  (154.3  grs.)  of  bihydrochlorid 
of  quinin,  18  grams  (277.7  grs.)  of  distilled  water,  5 
grams  (77.1  grs.)  of  ethylurethane.  Of  this  quantit}-  one- 
twenty-fifth  portion  is  used  for  an  injection.  One  and  a 
half  mils  (25  ni.)  of  the  solution  contain  five-tenths  of  a 
gram  (7.71  grs.)  of  quinin.  This  solution  is  often  re- 
ferred to  as  Gaglio's  or  Giemsa's.  Where  it  is  possible  to 
give  quinin  by  mouth,  this  may  ])e  done  with  suitable  doses 
of  quinin  sulphate,  to  which  5  to  10  minims  (0.30  to  0.60  mils) 


234  TROPICAL   DISEASES. 

of  dilute  sulphuric  acid  have  been  added,  with  syrup  of  orange 
and  distilled  water.     The  prescription  per  dose  is  as  follows : 

■     IJ  Quinin  sulphate 65  (10  gr.). 

Sulphuric  acid  dilute 12  (10  in). 

Syrup  of  orange 4  mils  (64.8  m). 

Distilled  water q.  s.  25  mils  (6.7  f3). 

It  is  generally  held  that  quinin  absorbs  much  more  rapidly 
when  administered  in  an  acid  solution. 

During  the  chilly  stage  patients  can  usually  be  made  very 
comfortable  and  the  chill  promptly  stopped  by  the  injection 
of  10  drops  (0.62  mils)  of  chloroform.  If  this  fails  imme- 
diately to  relieve  the  chill,  morphin  sulphate  in  %-grain 
(0.01  Gm.)  doses,  given  hypodermically,  generally  brings 
relief.  The  headache  is  greatly  relieved  by  cold  applications. 
When  ice  is  not  available,  cloths  may  be  soaked  in  a  mixture 
composed  of  salt,  fresh  limes  or  lemons,  with  vinegar  or  weak 
acetic  acid,  and  some  eau-de-Cologne.  These  have  a  very 
cooling  effect,  and  should  be  changed  as  frequently  as  they 
become  warm.  Acetanilid  and  caffein  also  may  be  employed 
to  relieve  the  severe  headache.  Vomiting  frequently  can  be 
relieved  by  sips  of  iced  soda-water  or  champagne.  If  the 
vomiting  is  severe  and  not  relieved  by  the  foregoing,  a  small 
mustard,  or,  preferably,  a  capsicum  plaster  may  be  applied  to 
the  pit  of  the  stomach.  Gastric  lavage  may  be  undertaken  in 
severe  cases  to  relieve  the  vomiting.  The  treatment  of 
malaria  should  invariably  be  begun  by  ^-grain  (0.01  Gm.) 
doses  of  calomel,  given  at  hourly  intervals  until  free  purga- 
tion takes  place.  Many  practitioners  follow  calomel  with  suit- 
able doses  of  magnesium  sulphate,  but  experience  shows  that 
this  is  scarcely  necessary,  and  only  makes  the  patient  more 
uncomfortable.  The  usual  liquid  diet  should  be  given  during 
the  fever  periods,  and  even  during  the  intervals  of  apyrexia 
it  is  well  to  allow  only  easily  digested  foods.  Meat,  as  a  rule, 
is  borne  badly.  In  chronic  malaria,  after  regular  quinin 
treatment,  a  change  of  climate  is  most  desirable  and  usually 
necessary,  if  prompt  permanent  convalescence  is  to  be  estab- 
lished. A  tonic  should  be  given  as  soon  as  convalescence 
begins.  The  U.  S.  P.  preparation  of  the  elixir  of  iron,  quinin 
and  strychnin,  is  among  the  best  that  can  be  employed. 


MALARIAL   FEVER.  235 

Prophylaxis.  Malarial  fever,  especially  the  appearance  of 
new  cases,  depends  upon  the  exposure  of  numerous  human 
beings  infected  with  male  and  female  gametocytes  to  Ano- 
pheles mosquitoes  in  which  gametocytes  are  capable  of 
developing  into  sporozoites,  and  suitable  temperature  condi- 
tions for  the  development  of  the  parasite  in  the  mosquito. 
Much  success  has  been  had  in  bringing  malarial  fever  under 
control  in  various  countries  of  the  world.  For  instance,  Ross 
achieved  great  success  in  Ismailia;  in  Panama  excellent 
results  were  obtained,  likewise  in  the  Philippines,  and  more 
recently  in  the  Federated  Malay  States.  Unfortunately  the 
cost  of  these  mosquito-control  measures  has  been  greater 
than  the  funds  which  could  be  made  available  in  the  average 
district.  In  other  words,  the  per  capita  taxpaying  power 
of  the  average  community  is  not  sufficiently  great  to  carry 
out  malarial  measures  that  are  as  expensive  as  those  cited 
above.  It  is  true  that  considerable  success  has  been  had  on 
a  small  scale  in  bringing  malaria  under  control  in  many  parts 
of  the  world  at  a  cost  which  was  reasonable,  but  these  are 
only  isolated  instances,  and  there  is  as  yet  no  feasible  plan 
for  bringing  about  the  control  of  malarial  fever  through  the 
elimination  of  mosquitoes  at  a  cost  which  would  make  its 
adoption  universally  practicable. 

From  the  foregoing  it  will  be  apparent  that  malaria  is  a 
controllable  disease.  From  the  theoretical  standpoint  control 
is  simple;  The  malarial  parasite  has  two  hosts,  man  and  cer- 
tain mosquitoes  belonging  to  the  Anophelincc  group.  Both  of 
these  hosts  are  necessary  to  the  perpetuation  of  the  parasite 
and  of  the  disease,  so  that  theoretically  it  is  only  necessary 
to  break  a  link  in  this  chain.  Every  infected  person  has 
derived  his  infection  from  an  infected  mosquito,  which  in  turn, 
has  derived  its  infection  from  an  infected  person,  so  that  if 
blood  of  man  can  be  sterilized,  so  far  as  the  malarial  parasite 
is  concerned,  a  mosquito  would  have  no  place  from  which  to 
derive  its  infection.  On  the  other  hand,  if  mosquitoes  could 
be  eliminated,  there  would  be  no  means  to  convey  the  infec- 
tion from  one  human  being  to  another,  and  the  disease  would 
automatically  stop.  At  the  present  time  a  number  of  experi- 
ments are  being  conducted  in  the  Southern  States,  with  a 
view  to  determining  exactly  the  per  capita  cost  of  eradicating 


236  TROPICAL   DISEASES. 

malaria  under  different  circumstances  and  under  different 
methods.  One  of  these  consists  in  taking  a  selected  com- 
munity and  making  a  blood  examination  in  the  spring  of  all 
the  persons  before  the  mosquitoes  become  active,  and  in  treat- 
ing with  quinin  those  found  infected.  The  other  experiment 
consists  in  attempting  to  eliminate  Anopheles  mosquito  breed- 
ing-places from  the  vicinity  of  human  habitations  by  simple 
drainage  or  with  larvae-destroying  agents.  None  of  these 
experiments  has  yet  been  completed,  but  experience  with  the 
first  experiment  shows  that  persons  who  are  carriers  of 
malaria  cannot  be  sterilized  by  the  administration  of  quinin 
in  10-grain  (0.65  Gm.)  daily  doses  over  a  period  of  several 
weeks.  Even  20-grain  (1.3  Gms.)  doses  given  over  a  period 
of  several  weeks  do  not  cause  a  complete  disappearance  of 
the  malarial  parasite  in  every  individual.  A  similar  experi- 
ment, but  not  upon  so  intensive  a  plan,  has  been  carried  out 
in  Italy.  It  has  been  shown,  for  instance,  in  certain  districts 
of  Italy  that  the  number  of  malarial  deaths  seems  to  be  in 
direct  proportion  to  the  quantity  of  quinin  sold.  For  in- 
stance, in  1901  there  were  13„861  deaths  recorded  in  Italy.  In 
1902,  2242  kilos  of  quinin  were  sold,  and  the  deaths  dropped 
to  9908.  In  1906,  20,723  kilos  of  quinin  were  sold,  and  the 
deaths  dropped  to  4871.  In  1900  Koch  conducted  a  similar 
experiment  in  New  Guinea,  but  upon  a  very  much  smaller 
scale.  Among  157  persons  who  harbored  the  malarial  para- 
site he  administered  1  gram  (15.4  grs.)  of  quinin  every 
eighth  or  ninth  day  until  the  malarial  parasite  disappeared. 
The  number  of  hospital  admissions  was  reduced  in  a  period 
of  six  months  from  twenty-four  to  one.  A  similar  experiment 
was  made  by  Heiser  in  the  Philippines  at  the  Iwahig  Penal 
Colony,  where  the  precautions  were  adequate  to  insure  that 
the  quinin  actually  reached  the  stomach.  He  administered  5- 
grain  (0.32  Gm.)  doses  of  quinin  to  1000  prisoners  daily.  In 
addition,  the  use  of  mosquito-nets  was  insisted  upon.  There 
was  an  enormous  reduction  in  the  number  of  new  cases,  but 
after  a  year's  trial  it  became  evident  that  the  quinin  adminis- 
tered did  not  give  complete  protection,  and  that,  perhaps,  the 
results  obtained  were  also  largely  contributed  to  by  the  strict 
use  of  mosquito-nets.  It  was  found,  for  instance,  that  when 
prisoners  who  were  taking  the  regular  doses  of  quinin  slept  in 


MALARIAL   FEVER.  237 

camps  in  the  jungle  and  were  not  protected  by  the  mosquito- 
nets,  they  almost  invariably  contracted  malarial  fever.  This 
experiment  was  also  interesting,  owing  to  the  fact  that  there 
were  no  persons  residing  within  the  flight  of  the  mosquitoes 
who  did  not  receive  daily  doses  of  quinin.  Any  measure 
which  gives  an  individual  protection  from  mosquitoes  at 
night  is  more  than  likely  to  reduce  the  incidence  of  malarial 
fever.  Recent  observations  made  in  Sandakan,  Borneo, 
showed  that  in  a  school  which  was  attended  by  students  who 
lived  at  the  school  and  those  who  attended  only  during  the 
day,  the  infection  among  those  who  slept  in  the  school  was 
very  much  heavier  than  those  who  slept  outside.  It  was 
shown  that  the  pupils  in  the  school  lived  in  a  district  in  which 
the  Anopheles  mosquito  bred  freely,  and  they  were  not  pro- 
tected by  mosquito-nets,  whereas  the  day  pupils  lived  in  their 
own  homes  in  districts  comparatively  free  from  mosquitoes 
and  slept  under  mosquito-nets. 

It  is  obvious  from  what  has  been  stated  above  that 
malarial  control  in  the  future  must  largely  depend  upon  the 
wide  dissemination  of  knowledge  with  regard  to  the  manner 
in  which  the  disease  is  spread.  The  best  hope  of  bringing 
this  about  would  seem  to  be  to  have  the  subject  thoroughly 
taught  in  the  public  schools,  and  also  to  have  public  lectures 
with  lantern  demonstrations  for  adults. 

For  persons  who  are  compelled  to  go  temporarily  into 
malarious  districts  reasonable  protection  against  infection 
may  be  had  by  the  administration  of  10-grain  (0.65  Gm.) 
daily  doses  of  quinin  and  the  rigid  use  of  mosquito-nets. 
Koch  thought  1  gram  (15.4  grs.)  once  a  week  was  sufficient. 
Whether  persons  who  actually  live  or  make  long  sojourns  in 
malarious  districts  can  take  sufficiently  large  daily  doses  of 
quinin  to  give  themselves  protection  is  an  open  question. 
The  best  hope  of  success  for  such  persons  would  seem  to  lie 
in  an  attempt  to  prevent  mosquitoes  breeding  in  the  neigh- 
borhood of  their  habitations,  to  use  mosquito-nets,  and  to 
have  their  living  quarters  thoroughly  screened  against  mos- 
quitoes. 

The  Anopheles  Mosquito.  Experience  so  far  has  shown 
that  in  order  to  luring  malarial  fever  under  control  it  is  not 
necessary   to   bring  about   complete   eradication.      If,   for   in- 


238  TROPICAL   DISEASES. 

stance,'  the  mosquito  index  for  a  community  is  100  per  cent., 
if  a  90  per  cent,  reduction  is  made  in  the  number  of  mos- 
quitoes, it  is  more  than  likely  that  malaria  will  disappear. 
This  is  a  most  important  observation,  and  has  great  practical 
value.  In  many  communities  it  is  possible  to  bring  about  a 
great  reduction  in  mosquitoes,  but  it  is  not  possible  to  eradi- 
cate them  completely.  In  general,  it  may  be  stated  that  if  a 
50  per  cent,  reduction  can  be  brought  about  in  the  number  of 
mosquitoes,  the  results  in  a  reduced  number  of  malarial  cases 
will  be  in  proportion  to  the  percentage  which  is  reached,  about 
50  per  cent.  The  practical  measures  for  eliminating  mos- 
quitoes may  depend  upon  drainage,  and  upon  the  spreading 
over  the  water  surfaces  some  larvicide,  as,  for  instance,  kero- 
sene oil.  Experience  in  the  Philippines  has  shown  that  a 
desirable  mixture  can  be  made  with  ordinary  cheap  kerosene 
and  crude  petroleum  in  equal  parts.  "Larvacide,"  which  is  a 
preparation  successfully  used  in  Panama,  is  made  as  follows : 

Carbolic  acid  crude   150  gals.  (600  1.). 

Rosin    20  lbs.  (9.07  Kg.). 

Caustic  soda    30  lbs.  (13.60  Kg.). 

Water    6  gals.  (24  1.). 

This  solution  actually  mixes  with  the  water  in  which  it  is 
placed,  and  is  very  destructive  to  larvicidal  growth,  but  it  also 
destroys  plant  life,  and  should  be  used  with  caution  where 
this  is  objectionable.  Oiling  of  water  surfaces  should  be  done 
at  intervals  of  at  least  every  ten  days,  because  an  adult  mos- 
quito, under  favorable  conditions,  may  develop  in  eleven  to 
twelve  days  after  the  deposition  of  the  egg  on  the  surface  of 
the  water. 

Briefly,  then,  the  whole  question  of  prophylaxis  may  be 
summed  up  by  the  statement  that  up  to  the  present  time  no 
definite  conclusions  have  been  reached  as  to  the  best  and  most 
economical  methods  to  employ  for  a  given  set  of  conditions. 
Each  case  must  be  decided  upon  whether  it  would  be  better 
to  use  a  combination  of  the  quinin,  mosquito-net  and  mos- 
quito-destruction measures,  or  whether  a  single  measure  or 
more  should  be  used. 


YELLOW   FEVER.  239 

YELLOW    FEVER. 

Yellow  fever  is  an  acute  febrile  disease  of  unknown  origin, 
characterized,  as  a  rule,  by  two  paroxysms  of  fever,  which 
are  separated  by  a  remission  or  an  intermission,  accompanied 
with  albuminuria,  jaundice,  hemorrhages  from  the  stomach, 
and  no  particular  change  in  the  leucoc3^te  count.  It  is 
transmitted  by  the  Stcgomyia  calopus  mosquito,  heretofore 
known  as  the  Stcgomyia  fasciata. 

Pestis  Americana,  Typhus  Icteroides,  Fibre  Amarilla, 
Magdalena  Fever  (Columbia),  Pest  of  Havana  (Cuba),  The 
Yellow  Jack,  are  synonyms  commonly  used  in  referring  to 
this  infection. 

The  origin  of  the  disease  is  shrouded  in  considerable  mys- 
tery. It  has  been  reported  as  having-  been  originally  a  disease 
of  the  Antilles,  and  to  have  attacked  the  troops  of  Christopher 
Columbus  in  1495  in  Santo  Domingo,  whence  it  was  carried 
to  the  mainland  of  America.  The  endemic  home  of  the  dis- 
ease is  at  present  in  or  near  Guayaquil,  and  in  the  vicinity  of 
Bahia.  In  the  past  few  years  it  has  been  frequently  carried 
to  Central  and  other  South  American  countries,  but  appar- 
ently has  gained  no  permanent  foothold.  As  a  result  of  the 
efforts  of  American  sanitarians  it  has  disappeared  completely 
from  Cuba  and  Panama.  Similar  work  in  Rio  de  Janeiro  has 
produced  results  almost  as  good.  The  disease  frequently  is 
reported  as  occurring  on  the  Gold  Coast  of  Western  Africa, 
but  the  diagnosis  of  yellow  fever  is  not  universally  accepted. 
In  the  past  it  has  been  carried  to  Spain  and  Italy,  but  it  never 
gained  permanent  foothold  in  these  countries.  Until  compara- 
tively recent  times  it  was  frequently  carried  to  the  ports  of  the 
Atlantic  seaboard  of  America  south  of  Baltimore  and  along 
the  Gulf  of  Mexico.  During  the  early  part  of  the  nineteenth 
century  the  disease  appeared  as  far  north  as  Philadelphia. 

In  1881,  Charles  Finley,  of  Havana,  formulated  the  hypo- 
thesis that  the  spread  of  yellow  fever  was  through  the  mos- 
quito. In  1882  Gererd  permitted  himself  to  be  bitten  by  a 
mosquito  which  had  fed  on  a  yellow  fever  patient  on  the 
fourth  day  of  the  disease,  and  he  in  turn  contracted  an  attack 
of  yellow  fever.  In  1897  Sanarelli  announced  that  he  had 
found   the   bacterium   of  yellow   fever,   which   he   named   the 


240  TROPICAL   DISEASES, 

Bacillus  icteroides.  These  findings  were  confirmed  by  other 
observers.  In  1900  Reed  and  Carroll  announced  that  the 
Bacillus  icteroides  belonged  to  the  hog-cholera  group,  and  was 
probably  identical  with  the  Bacillus  cholercc  suis.  Numerous 
other  workers  have  reported  on  the  causative  agent,  but  it 
may  be  stated  that  none  of  these  various  organisms  have 
withstood  the  test  of  time,  and  the  true  etiology  of  the  dis- 
ease is  still  unknown.  In  1900  Reed,  Carroll,  Agramonte  and 
Lazear  proved  that  the  disease  could  be  produced  by  the  sub- 
cutaneous injection  of  infected  blood  into  a  non-immune  per- 
son ;  also  that  the  disease  was  not  contagious,  and  that  it  was 
only  spread  by  the  bite  of  the  Stegomyia  calopus.  Their  work 
was  speedily  confirmed  by  many  workers  of  numerous  nation- 
alities. In  1909  Seidelin  described  the  presence  of  minute 
bodies,  which  he  called  Paraplasma  flavigcnum,  in  the  red  cells 
of  persons  suffering  from  yellow  fever.  This,  however,  has 
not  been  very  generally  confirmed.  The  theory  of  the  propa- 
gation of  yellow  fever  by  the  Stegomyia  calopus  has  been 
tested  practically  with  good  results  in  Havana,  Texas,  Mexico, 
New  Orleans,  Panama  and  Rio  de  Janeiro.  The  discovery  of 
the  means  of  transmission  of  yellow  fever  by  the  mosquito 
was  one  of  the  first  important  American  achievements  in 
tropical  medicine.  It  should  also  be  mentioned  that  Lazear 
sacrificed  his  life  in  permitting  the  yellow  fever  mosquitoes 
to  bite  him. 

In  brief,  it  may  be  stated  that  yellow  fever  is  only  possible 
in  those  regions  of  the  world  in  which  the  calopus  mosquito 
thrives.  With  the  elimination  of  this  mosquito,  the  disap- 
pearance of  the  disease  invariably  results.  An  interesting 
phenomenon  is  the  fact  that  the  eradication  of  yellow  fever 
does  not  depend  upon  the  elimination  of  the  Stegomyia 
calopus.  Judging  by  the  experiences  in  Havana  and  Rio  de 
Janeiro,  it  seems  quite  likely  that  if  a  90  per  cent,  reduc- 
tion in  the  number  of  mosquitoes  can  be  effected,  the  disease 
will  disappear.  The  disease  may  spread  through  the  agency 
of  ships  or  other  methods  of  transportation  which  are  capable 
of  conveying  Stegomyia  calopus  from  areas  in  which  yellow 
fever  prevails.  The  opportunities  for  spreading  the  disease 
into  far  removed  countries  is  immeasurably  increased  by  the 
presence  on  board  vessels  of  persons  who  are  afflicted  with 


YELLOW    FEVER.  241 

the  disease  who  may  come  in  contact  with  Stegomyia  mos- 
quitoes on  the  ship  or  on  shore.  It  appears  that  frost,  which 
results  in  the  destruction  of  mosquitoes,  invariably  brings  an 
outbreak  of  yellow  fever  to  a  close. 

That  the  infection  of  yellow  fever  exists  in  the  blood  can 
readily  be  prpven  by  the  fact  that  subcutaneous  inoculation  of 
0.12  of  a  mil  (2  ?n.)  of  infected  blood  into  a  non-immune  person 
will  produce  an  attack  of  the  disease,  provided  that  the  blood 
has  been  drawn  from  an  infected  individual  during  the  hrst 
three  days  of  illness.  It  is  not  likely  to  be  transmitted  to  man 
by  post-mortem  wounds,  because  death  usually  does  not  take 
place  until  after  the  third  day  of  the  illness,  when  the  patient 
is  no  longer  in  an  infective  st-ate.  For  the  transmission  of  the 
disease  by  mosquitoes,  it  is  necessary  for  the  mosquitoes  to 
bite  the  individual  during  the  first  three  days  of  the  disease, 
and  then  twelve  days  must  elapse  before  the  mosquito  is 
capable  of  transmitting  the  infection.  The  proof  of  the  trans- 
mission of  the  disease  by  the  Stegomyia  calopus  mosquito  is 
furnished  by  Reed,!-^  Carroll,!^  Agramontei''  and  Lazear,!*^ 
through  the  construction  of  a  mosquito-proof  building,  which 
was  divided  into  two  compartments,  in  the  first  of  which 
infected  mosquitoes  were  liberated  and  allowed  to  bite  a  non- 
immune, while  in  the  second  compartment  non-immunes 
slept.  The  man  in  the  first  compartment  developed  an  attack 
of  yellow  fever,  while  the  others  did  not.  Further  proof  came 
from  the  fact  that  non-immunes  who  lived  in  mosquito-proof 
houses,  with  articles  of  clothing  and  bedding  soiled  with  the 
discharges  of  yellow  fever  cases,  did  not  contract  the  disease ; 
while  non-immunes  who  were  kept  free  from  such  infection, 
but  exposed  to  mosquitoes  that  had  bitten  yellow  fever  cases, 
did  contract  the  disease. 

The  experiments  of  Marchoux  and  Simond^'^  seem  to  indi- 
cate that  the  infection  can  be  transmitted  through  mosquito 
eggs,  and  thus  a  second  generation  of  mosquitoes  may  be 
transmitters  of  the  disease.  It  is  also  more  than  likely  that 
the  only  reservoir  for  the  disease  is  the  human  and  the  mos- 
quito. Apparently  chimpanzees  have  been  infected,  but  it  is 
unlikely  that  they  are  an  important  factor  in  the  transmission 
of  the  disease  to  man. 

There   are   usually   numerous   changes   in  the   liver.     The 

16 


242  TROPICAL   DISEASES. 

cells  swell  and  press  upon  the  bile  capillaries,,  and  thus  ob- 
struct the  flow  of  bile  and  cause  hepatogenous  jaundice.  This 
swelling  also  blocks  the  intralobular  capillaries,  which  causes 
congestion  in  the  viscera  drained  by  the  portal  circulation. 
The  liver  cells  usually  degenerate  so  extensively  as  to  cause 
a  lessening  in  the  urea  function,  and  often  a  condition  of 
ammoniemia  may  occur,  from  which  serious  toxic  effects  in 
the  brain  and  other  organs  are  to  be  expected.  The  disease 
often  seriously  affects  the  endothelial  lining-  of  the  blood 
capillaries,  and  causes  hemorrhages  in  various  parts  of  the 
body.  The  attack  usually  confers  a  permanent  immunity.  In 
countries  in  which  yellow  fever  is  epidemic  it  is  more  than 
likely  that  children  have  mild  attacks  which  go  unnoticed,  and 
they  therefore  become  immune.  In  yellow  fever  countries  it 
is  very  rare  to  find  that  the  disease  occurs  among  persons  who 
have  been  many  years  resident.  It  is  usually  the  newcomers 
who  are  affected. 

There  may  be  a  slight  increase  in  the  number  of  leuco- 
cytes, but  this  is  not  usual.  In  brief,  it  may  be  stated  that 
few  changes  are  to  be  looked  for  in  the  blood. 

Albumin  appears  early,  very  often  on  the  second  day,  and 
increases  in  quantity,  especially  in  severe  cases.  This  symp- 
tom, in  combination  with  the  fever  and  jaundice,  is  usually 
greatly  depended  upon  for  a  diagnosis.  Bile  is  usually  pres- 
ent in  the  urine  on  the  fifth  or  sixth  day ;  and  casts  are  the 
rule,  first  hyaline,  then  granular,  and  finally  epithelial.  The 
amount  of  urea  is  greatly  diminished,  and  the  quantity  of 
urine  is  scanty. 

The  material  vomited  by  the  patient  is  usually  referred  to 
as  black  vomit,  since  it  consists  largely  of  blood  and  mucus. 
In  some  instances  the  vomit  may  be  red,  in  which  event  it 
is  composed  of  bright  blood  which  has  not  had  an  opportunity 
to  coagulate.  Microscopically,  the  vomit  is  found  to  consist 
of  red  blood-corpuscles,  epithelial  cells,  debris  and  micro- 
organisms. 

The  skin  is  bile-stained  and  blotched  with  post-mortem 
lividity  and  hemorrhages.  The  liver  is  yellowish  in  color  and 
hemorrhagic,  with  the  cells  swollen  and  in  a  state  of  advanced 
fatty  degeneration.  The  gall-bladder  contains  thickened  bile, 
which  is  sometimes  mixed  with  blood.     The  spleen  is  normal 


YELLOW    FEVER.  243 

in  size.  The  stomach  and  intestines  are  often  filled  with 
blood.  The  kidneys,  normal  in  size  and  frequently  congested, 
as  a  rule,  show  evidences  of  acute  nephritis.  The  cells  of  the 
tubules  show  fatty  degeneration,  and  the  lumen  may  contain 
granular  debris.  The  bladder  is  usually  empty.  The  serous 
surfaces  of  the  heart  frequently  show  punctiform  hemor- 
rhages, and  effusions  may  occur  in  the  pericardium.  The 
lungs  are  congested,  and  hemorrhages  are  often  found  be- 
tween the  pleura.  The  uterine  mucosa  is  congested,  and  there 
may  be  blood  in  the  canal.  The  meninges  of  the  brain  are 
congested  and  hemorrhagic  areas  are  frequent. 

The  incubation  period  of  yellow  fever  may  be  safely' 
placed  between  two  and  six  days,  and  this  premise  is  an 
important  factor  in  determining  the  diagnosis.  The  average 
period  of  incubation  appears  to  be  about  five  days.  The 
attack  usually  begins  with  headache,  flushed  face,  injected 
eyes,  and  pains  in  the  body,  particularly  in  the  back.  Albu- 
minuria appears  on  the  second  day.  The  temperature  may  be 
divided  into  two  paroxysms.  The  first  lasts  for  from  two  to 
four  days,  after  which  the  fever  usually  subsides  to  normal, 
accompanied  by  sweating.  In  some  instances  it  only  remits  to 
about  100°  F.  (37.7°  C),  but  the  symptoms  largely  disappear. 
At  the  end  of  this  first  paroxysm  convalescence  may  begin. 
When  this  does  not  occur  after  a  period  of  a  day  there  is  a 
sharp  rise  in  the  temperature,  which  is  not  accompanied  by  a 
corresponding  increase  in  the  pulse  rate.  As  jaundice  appears 
at  about  this  time,  this  is  naturally  to  be  expected.  However, 
it  is  of  the  greatest  diagnostic  importance.  The  jaundice 
which  accompanies  the  second  paroxysm,  plus  the  fever,  gives 
the  name  Yellow  Fever  to  the  disease.  The  appetite  is  lost 
from  the  beginning,  and  there  is  usually  vomiting,  associated 
with  pain  and  tenderness  over  the  gastric  region.  Constipa- 
tion is  the  rule.  The  urine  is  high  colored,  decreased  in 
amount,  with  acid  reaction,  and  high  specific  gravity.  In- 
somnia during  the  early  state  of  the  disease  is  frequent. 
During  the  secondary  rise  of  temperature  all  the  symptoms 
of  the  first  paroxysm  return,  especially  the  vomiting  and  ten- 
derness in  the  gastric  region.  Hemorrhages  may  occur  from 
the  nose,  mouth  or  uterus,  and  black  vomit  is  common. 
Albumin   increases  rapidly.     In   severe   cases   there   may  be 


244  TROPICAL   DISEASES. 

complete  suppression  of  urine.  Delirium  is  common,  accom- 
panied with  much  restlessness.  In  cases  in  which  there  is  a 
favorable  termination,  after  the  third  day  there  is  usually  an 
increase  of  the  amount  of  urine,  a  decrease  of  the  albumin, 
and  then  vomiting-  gradually  ceases ;  the  patient  passes  into 
deep  sleep,  and  is  then  well  on  the  road  to  convalescence.  If 
the  outcome  is  fatal,  the  temperature  continues,  the  jaundice 
deepens,  hemorrhages  appear  under  the  skin,  and  there  are 
hiccough,  subsultus  tendinum,  clammy  sweats,  complete  sup- 
pression of  the  urine,  coma,  and  convulsions,  which  lead  to 
death.  Death,  however,  may  take  place  before  respiratory 
and  cardiac  failures  can  occur. 

Yellow  fever  usually  is  described  by  different  authors  as 
occurring  in  a  number  of  types.  It  is  most  difficult  to  draw 
any  sharp  distinction  between  the  dififerent  types.  In  general, 
the  cases  are  either  mild,  severe  or  malignant,  with  symptoms 
that  correspond  to  these  conditions.  The  malignant  type  very 
often  begins  with  a  fever  of  105°  to  107°  F.  (40.5°  to  41.6°  C), 
with  violent  vomiting  and  the  early  appearance  of  black  vomit, 
and  the  patient  dies  during  the  first  paroxysm  of  fever  without 
any  remission  in  the  temperature  having  taken  place. 

Those  who  have  any  pathologic  condition  usually  resist 
yellow  fever  badly,  while  those  who  are  in  robust  health  show 
the  greatest  percentage  of  recoveries.  Renal  and  cardiac 
affections  are  particularly  unfavorable  complications,  and 
usually  persons  afflicted  with  them  succumb  to  the  disease. 

The  convalescence,  as  a  rule,  is  neither  complicated  nor 
protracted,  but  at  times  boils,  abscesses,  dysentery  and 
inflammation  of  the  liver  may  occur. 

The  mortality  varies  very  greatly  in  different  outbreaks. 
There  have  been  mild  outbreaks  in  which  the  mortality  has 
been  only  about  10  per  cent. ;  whereas  in  the  United  States 
it  sometimes  rises  to  25  per  cent.,  and  in  West  Africa  from  45 
per  cent,  to  80  per  cent.  Yellow  fever  must  be  regarded  as 
a  serious  disease,  especially  if  complicated  with  some  pre- 
existing disorder. 

During  an  epidemic  the  typical  symptoms  enumerated 
above  are  usually  sufficient  to  establish  a  diagnosis,  but  the 
first  cases,  and  especially  mild  attacks  of  the  disease,  are  most 
difficult  to  recognize.     Among  the  best  signs  for  dependable 


YELLOW   FEVER.  245 

diagnosis  are  the  early  albuminuria,  the  gastric  tenderness, 
the  jaundice,  the  secondary  rise  in  temperature  and  the  black 
vomit.  The  disease  usually  has  to  be  differentiated  from 
dengue,  subtertian  malaria,  blackwater  fever  and  relapsing 
fever.  Dengue  may  be  recognized  by  the  absence  of  marked 
albuminuria  and  jaundice;  subtertian  malaria  by  the  parasites 
in  the  blood ;  blackwater  fever  by  the  presence  of  hemoglobin 
in  the  urine  and  the  increase  in  the  mononuclear  lymphocytes ; 
and  relapsing  fever  by  the  parasites  in  the  blood  and  the 
leucocytosis. 

TREATMENT. 

As  the  cause  of  the  disease  is  not  known,  the  best  hope  of 
success  is  directed  toward  a  rapid  elimination  of  the  toxins, 
and  bringing  comfort  to  the  patient.  An  important  consid- 
eration is  the  prophylaxis  of  the  disease.  Th^'s  is  best  accom- 
plished by  effectively  screening  the  patient  from  mosquitoes 
and  the  destruction  of  those  mosquitoes  in  the  house  which 
may  have  bitten  the  patient.  The  treatment  must  be  directed 
mainly  toward  stimulation  of  the  organs  of  elimination,  that 
is,  the  bowels,  skin  and  kidneys.  The  bowels  are  to  be 
opened  by  small  doses  of  calomel,  followed  by  magnesia  or 
sodium  sulphate,  until  active  purgation  has  been  produced. 
The  free  action  of  the  bowels  can  be  continued  by  the  admin- 
istration of  tablespoonful  doses  of  sodium  sulphate  dissolved 
in  a  pint  of  water  and  given  morning  and  night.  Hot  blankets 
and  hot-water  bottles  promote  the  free  action  of  the  skin.  In 
order  to  dilute  the  toxins  and  to  stimulate  action  of  the  kid- 
neys, plenty  of  alkaline  fluids  are  desirable.  These  can  be 
supplied  by  the  use  of  from  2  to  4  quarts  (liters)  of  Vichy  or 
Poland  water,  or  the  same  quantity  of  any  reliable  alkaline 
mineral  water.  If  none  of  these  are  available  a  substitute  may 
be  made  by  adding  30  grains  (1.95  Gms.)  of  sodium  bicarbo- 
nate to  a  pint  of  water.  An  effervescing  drink  can  be  made  by 
the  use  of  sodium  bicarbonate  and  fresh  lime-juice.  Care 
should  be  taken  to  use  the  mixture  in  neutral  quantities.  This, 
if  necessary,  may  be  brought  about  by  the  use  of  sodium  sul- 
phate. If  fluids  cannot  be  given  by  the  mouth,  enemata 
should  be  used.  The  headache  and  pains  in  the  back  muscles 
may  be  relieved  by  3-grain   (0.195   Gm.)   doses  of  acetanilid. 


246  TROPICAL   DISEASES. 

The  severe  pains  in  the  back  may  be  further  relieved  by  hot 
«ipplications.  Vomiting  may  be  controlled  by  the  use  of  iced 
champagne,  and  at  times  by  counter-irritation  in  the  form  of 
a  blister  over  the  stomach.  The  fever  may  be  reduced  by  cold 
sponging.  Vomiting  sometimes  may  be  checked  by  the  use 
of  the  ice-bag  over  the  stomach.  The  weakening  heart  must 
be  supported  by  injections  of  strychnin,  followed,  for  more 
permanent  effect,  by  small  doses  of  digitalin.  Camphor  is 
also  valuable.  Milk  with  lime  and  barley-water  is  the  dietary 
mainstay.  Ice-cream,  and  wine  and  lemon  jellies,  are  also 
desirable.  The  return  to  solid  food  after  the  absence  of  high 
temperature  should  not  be  undertaken  until  at  least  three 
days  have  elapsed.  Solid  food  seems  to  be  very  badly  borne 
by  those  who  have  passed  through  a  severe  attack  of  yellow 
fever.  Death  may  occur  from  overeating  during  conval- 
escence. 

Prophylaxis.  To  prevent  the  spread  of  yellow  fever  it  is 
only  necessary  to  prevent  mosquitoes  which  have  bitten  in- 
fected individuals  between  the  second  and  fifth  day  of  the  dis- 
ease from  reaching  other  individuals  twelve  days  or  more  after- 
ward. The  patient  should  be  kept  under  a  mosquito-net.  The 
house  should  be  thoroughly  screened.  In  all  places  where  yel- 
low fever  has  appeared  fumigation  of  the  premises  should  be 
carried  out,  in  order  to  kill  any  possible  mosquitoes.  This 
can  be  done  by  burning-  2  pounds  of  sulphur  for  each  thou- 
sand cubic  feet  of  air  space.  The  sulphur  is  best  burned  in 
an  iron  pot,  which  has  been  set  in  a  receptacle  containing 
water.  The  doors  and  windows  must  be  closed  and  cracks 
sealed  by  the  means  of  pasted  paper.  Three  hours  is  ample 
time  for  the  fumes  to  act.  If  sulphur  cannot  be  used, 
pyrethrum  powder,  or,  as  it  is  sometimes  called,  Japanese 
powder,  may  be  used  in  the  proportion  of  2  pounds  (0.9  Kg.) 
to  each  thousand  cubic  feet  of  air  space.  However,  attention 
should  be  drawn  to  the  fact  that  pyrethrum  g-ases  do  not  kill 
mosquitoes.  They  are  only  numbed,  and  immediately  after 
the  burning  has  been  completed  the  room  should  be  swept  and 
the  collected  mosquitoes  burned.  Quarantine  against  resi- 
dents of  yellow  fever  districts  is  unnecessary,  if  such  persons 
can  be  kept  free  from  the  bites  of  Stegomyia  mosquitoes. 
Ships  that  have  anchored  in  yellow   fever  ports  should  be 


DENGUE.  247 

fumigated  against  mosquitoes  after  exposure.  Attendants  at 
quarantine  stations  should  live  in  mosquito-proof  houses,  so 
that  possible  infection  among  them  may  not  spread  to  mos- 
quitoes. Mosquitoes  that  have  sucked  blood  from  dead  bodies 
seldom  are  infective,  because  patients  usually  do  not  die 
before  the  fifth  day  of  the  disease,  and  their  blood  is  no 
longer  infective  at  that  period  of  the  disease.  Screens  against 
mosquitoes  should  contain  eighteen  meshes  to  the  inch  (2.5 
cm.),  if  made  of  fine  wire,  or  a  correspondingly  smaller  num- 
ber of  meshes  if  the  wire  is  of  a  heavy  variety. 

DENGUE. 

There  are  many  synonyms  for  this  disease.  A  popular 
name  in  Texas  for  dengue  is  Breakbone  Fever,  and  in  other 
parts  of  the  world  it  is  variously  referred  to  as  Breakheart 
Fever,  Girafife  Fever,  Febris  Endemica  cum  Roseola  and 
Seven  Days'  Fever. 

Dengue  is  an  acute,  specific  fever  of  unknown  origin, 
usually  characterized  by  two  febrile  paroxysms,  separated  by 
an  intermission,  by  albuminuria  and  by  marked  leucopenia. 
Most  authorities  attribute  its  transmission  to  the  Culcx 
fatigans  mosquito.  Recent  work  (1916)  in  Australia  indicates 
that  it  also  may  be  spread  by  the  Stegomyia  fasciata. 

It  appears  to  have  been  recognized  in  Java  in  the  eigh- 
teenth century  by  Bylon,  but  there  are  old  descriptions  of 
disease  which  indicate  that  it  was  reported  even  at  an  earlier 
period  in  Seville.  In  general,  it  may  be  stated  to  exist  in 
those  areas  of  the  world  in  which  yellow  fever  has  occurred, 
or  in  which  the  Stegomyia  fasciata  mosquito  is  common. 
There  are  frequent  outbreaks  in  Texas.  It  is  a  very  disabling 
disease  in  Australia,  and  in  cities  like  Brisbane,  for  instance, 
the  entire  population  may  be  affected  before  an  outbreak 
comes  to  a  close.  Constant  efforts  have  been  made  through- 
out the  world  to  find  the  causative  organism,  but  so  far  with- 
out success. 

Graham, 18  Ashburn  and  Craigi"  have  done  the  work  which 
is  generally  considered  as  throwing  most  light  upon  its  trans- 
mission. Their  observations  lead  to  the  conclusion  that  the 
ciisease  is  intimately  associated  with  mosquitoes,    The  intra- 


248  TROPICAL   DISEASES. 

venous  injection  of  dengue-fever  blood  produces  typical  at- 
tacks of  the  disease  in  healthy  subjects  within  two  or  three 
days. .  There  is  no  evidence  of  the  spread  of  the  disease  other 
than  through  mosquitoes.  As  there  is  practically  no  mortal- 
ity from  dengue,  little  or  nothing  is  known  of  the  pathology 
of  the  affection.  The  lesions  in  persons  who  have  died  of 
some  intercurrent  affection  while  suffering  with  dengue  do 
not  show  anything  characteristic  beyond  the  lesion  of  the 
intercurrent  affection. 

Based  on  the  observations  of  Ashburn  and  Craig,  the 
incubation  period  is  from  three  to  six  days.  Some  authors 
report  that  prodromata  may  appear  several  days  before  the 
outbreak  of  the  disease,  but  this  is  unusual.  The  attack  is 
generally  sudden,  and  begins  with  severe  pain  in  some  part 
of  the  body.  Often  there  is  a  sensation  of  extreme  fatigue, 
and  chills  may  occur  at  times.  A  characteristic  onset  is  with 
great  pain  behind  the  eyeballs  and  intense  headache.  An- 
other very  common  symptom  is  great  pain  in  the  back,  par- 
ticularly in  the  sacroiliac  joint.  In  children  the  onset  may 
be  characterized  by  convulsions  or  delirium.  The  tempera- 
ture rises  rapidly,  and  usually  is  between  103°  and  106°  F. 
(39.5°  and  41.1°  C.)-  The  pulse  usually  increases  in  propor- 
tion, and  is  found  to  be  from  90  to  140  per  minute.  Very 
frequently  the  joints  are  painful.  As  a  rule,  the  joints  can 
be  moved  passively  without  causing  pain,  but  if  there  is  active 
movement  the  pain  is  severe.  In  rare  instances  there  is  red- 
ness and  swelling  in  the  joints.  The  general  character  of  the 
pains  aptly  may  be  described  by  a  quotation  from  Rip  Van 
Winkle :  "Every  time  I  make  a  new  move  I  have  a  new 
pain."  There  may  be  either  constipation  or  diarrhea.  The 
glands  are  not  enlarged.  Leucopenia  is  so  constant  that  it  is 
of  great  diagnostic  importance,  and  the  leucocyte  count  varies 
from  5000  to  1000,  the  average  being  about  3500  per  cubic 
millimeter.  The  leucocytes  are  normal  in  appearance,  but 
there  is  a  marked  increase  in  the  number  of  s'maller  lympho- 
cytes, and  a  commensurate  loss  of  the  polynuclear  forms. 
The  urine  is  highly  colored,  and  frequently  contains  traces  of 
albumin.  On  the  third  day  the  temperature  falls  rapidly,  and 
is  often  accompanied  by  profuse  perspiration,  the  passage  of 
much   urine,   violent   diarrhea   and   bleeding  from   the   nose. 


DENGUE.  249 

These  signs,  however,  may  be  absent.  The  patient  feels  much 
better.  This  intermission,  however,  may  be  entirely  lacking. 
When  it  does  occur  it  lasts  usually  until  the  fifth,  day,  when 
there  is  a  rapid  rise  in  the  temperature,  but  not  reaching  much 
over  103°  F.  (39.5°  C).  With  the  second  rise  in  temperature 
a  characteristic  rash  appears,  usually  beginning  in  the  palms 
and  backs  of  the  hands,  and  spreading  rapidly  to  the  arms, 
trunk  and  legs.  The  eruption  is  varied  in  character.  At 
times  it  consists  of  small  macules  which  gradually  extend  in 
size  and  coalesce  until  the  patient  resembles  a  scarlet-fever 
victim ;  but  this  is  unusual.  At  other  times  there  are  small 
macules,  with  close-set,  bright-red  points,  which  have  no  ten- 
dency to  spread,  and  separated  by  large  areas  of  normal-col- 
ored skin.  There  may  be  many  variations  of  these  two  types 
of  eruption.  Often  the  eruption  is  absent,  or  so  faint  that  it 
can  only  be  made  out  with  the  greatest  difficulty.  In  the 
average  outbreak  the  eruption  is  the  rule. 

The  temperature  is  also  subject  to  many  variations.  This 
is  especially  true  in  cases  that  have  had  a  previous  attack. 
As  a  rule,  the  second  attack  of  the  disease  is  not  nearh-  so 
severe  as  the  first  attack ;  the  third  is  even  milder,  and  a 
fourth  is  very  rare.  In  most  instances  the  convalescence  is 
quick  and  permanent^  but  in  some  individuals  *it  may  be 
greatly  prolonged,  and  exhaustion  from  slight  efifort  may  last 
for  many  weeks. 

In  rare  instances  there  may  be  hemorrhages  from  the 
mucosa  of  the  nose,  stomach,  intestines  or  uterus.  Pleurisy, 
pericarditis,  endocarditis  and  meningitis  occur  at  very  rare 
intervals.  The  most  important  sequel?e  are  pains  in  the  joints 
and  muscles,  and  these  often  give  great  distress. 

The  diagnosis  of  dengue  is  based  upon  the  sudden  onset, 
the  severe  pain  in  the  muscles  and  joints,  the  characteristic 
rash,  the  temperature,  and  the  absence  of  the  causative 
organism  of  diseases  with  similar  symptoms.  It  may  be  mis- 
taken for  yellow  fever,  malaria,  influenza,  scarlet  fever, 
measles,  rheumatic  fever,  smallpox  and  tonsillitis.  Yellow 
fever  is  readily  differentiated  by  its  slower  pulse,  jaundice 
and  hematemesis.  In  malaria  there  are  blood  parasites.  In 
influenza  there  is  the  absence  of  eruptions  and  the  presence 
of  the  usual  catarrhal  symptoms.     In  scarlet  fever  there  is 


250  TROPICAL   DISEASES. 

the  complicating  sore  throat,  with  the  enlarged  glands  of  the 
neck.  In  measles,  marked  catarrhal  symptoms,  followed  by 
the  characteristic  rash,  dominate  the  clinical  picture.  In 
rheumatic  fever  there  is  the  swelling  in  the  joints,  with  pain 
on  passive  motion.  It  is  very  often  difficult  to  dififerentiate 
smallpox  until  the  eruption  actually  appears.  Tonsillitis  may 
be  excluded  by  the  throat  symptom. 

In  the  tropics  enteric  fever  may  be  mistaken  for  dengue, 
but  the  continued  fever  and  the  constant  headache,  with  the 
absence  of  the  characteristic  joint  and  muscle  pains,  usually 
makes  it  possible  to  give  a  correct  diagnosis. 

The  mortality  is  practically  nothing.  In  Australia  it  is 
said  to  cause  one  death  in  1000.  These  occur  in  those  under 
5  and  over  60  years  of  age. 

There  is  no  specific  treatment  available.  Treatment 
should  invariably  be  begun  with  small  doses  of  calomel — say, 
of  /4o  grain  (0.006  Gm.) — and  administered  every  half-hour 
until  the  bowels  move  freely.  Great  relief  can  be  afforded 
the  patient  by  the  administration  of  salicylates  in  the  form 
of  aspirin  or  sodium  salicylate.  At  times  hypodermic  injec- 
tions of  %-grain  (0.010  Gm.)  doses  of  morphin  are  neces- 
sary to  relieve  the  pain.  During  the  febrile  period  the  patient 
can  be  made  comfortable  by  sponging  with  ice-water.  Cold 
drinks  should  be  administered  freely,  and  the  usual  fever  diet 
should  be  prescribed.  To  protect  the  heart  against  strain, 
rest  in  bed  is  essential. 

The  best  means  of  preventing  infection  is  to  exclude  mos- 
quitoes in  the  same  manner  as  is  done  in  yellow  fever  or 
malaria. 

MALTA    FEVER." 

Mediterranean  Fever,  Bruce's  Septicemia,  Neapolitan 
Fever,  Cyprus  Fever,  Undulant  Fever  apd  Septicemia  Meli- 
tensis  are  the  common  synonyms  used  for  this  infection, 
which  is  a  disease  of  long  duration,  characterized  by  febrile 
attacks  with  many  remittances.  It  is  caused  by  the  Micro- 
coccus melitensis,  and  usually  is  spread  through  goats' 
milk. 

Malta  fever  is  of  very  ancient  lineage.  Hippocrates 
described  cases  of  long-continued  fever  with  short  apyrexial 


MALTA    FEVER.  251 

intervals  which  lasted  one  hundred  and  twenty  days,  and  is  all 
probability  was  the  disease  we  call  Malta  fever  to-day.  In 
the  eighteenth  and  nineteenth  centuries  references  were  made 
by  Howard,  Hennen  and  Davy,  which  appear  to  have  been 
Malta  fever.  During  the  Crimean  War  the  incidence  of  the 
fever  was  greatly  increased  in  Malta,  but  it  was  difficult  to 
separate  it  from  the  typhoid  fever  which,  in  all  probability, 
prevailed  in  close  association  with  it.  In  1886  it  was  proved 
to  be  a  separate  pathologic  entity  by  Bruce,-"  who  discovered 
in  the  spleen  the  micrococcus  which  bears  his  name.  In  1887 
he  was  able  to  cultivate  the  micro-organism  on  agar,  and  to  repro- 
duce the  disease  by  inoculation  into  monkeys.  In  1891  he 
was  able  to  grow  the  germ  from  blood  which  had  been 
aspirated  from  the  spleen  during  life.  In  1897  Wright  and 
Semple-i  showed  that  the  disease  could  be  diagnosed  by  the 
agglutination  of  the  micrococcus  by  the  serum  of  patients. 
The  British  Admiralty,  the  War  Office,  and  the  Civil  Gov- 
ernment at  Malta  appointed  a  commission  to  investigate  the' 
disease  in  1904,^2  and  this  commission  showed  that  the  micro- 
organism leaves  the  body  mostly  through  the  urine,  and  that  it  is 
capable  of  existing  for  a  long  period  outside  of  the  body. 
The  commission  also  discovered  that  the  milk  of  many  goats 
would  agglutinate  the  Micrococcus  mclitcnsis,  and  later  they 
were  able  to  isolate  the  germ  from  goats  whose  milk  con- 
tained it.  Manson  reports-^  that,  unless  serum  reactions  are 
made  with  fresh  blood  and  proved  cultures,  erroneous  results 
may  follow. 

Prophylaxis  along  lines  indicated  by  the  etiology  has 
resulted  in  a  reduction  of  Malta  fever  among  the  British 
troops  in  Malta  from  643  cases  in  1905  to  one  case  in  1910.  In 
recent  years  more  careful  examinations  have  shown  that  the 
disease  also  exists  to  a  considerable  extent  in  Spain,  Portugal 
and  France. 

The  endemic  areas  of  the  disease  lie  along  the  coast  and 
islands  of  the  Mediterranean,  the  Punjab  in  India,  and  to  a 
limited  extent  in  Ceylon.  Strong  reported  one  case  in  the 
Philippine  Islands, ^-i  but  this  was  more  than  ten  years  ago, 
and  diligent  search  has  failed  to  reveal  additional  cases.  A 
few  isolated  cases  have  been  reported  in  England  and  the 
United    States.      It   seems   likelv    that   further    investigation 


252  TROPICAL   DISEASES. 

would  show  the  presence  of  the  disease  in  many  other  coun- 
tries. 

The  disease  is  caused  by  the  Micrococcus  melitcnsis 
(Bruce).  "  Castellani^^  expresses  the  opinion  that  a  closely 
allied  microbe  is  associated  with  the  disease  in  addition  to 
the  specific  micrococcus.  The  micro-organism  is  found  in  the 
spleen,  liver,  kidney,  lymphatic  and  salivary  glands.  It  may 
be  found  in  the  stomach  of  mosquitoes  which  have  fed  upon 
patients,  but  it  has  not  been  possible  to  prove  that  either 
mosquitoes,  flies  or  fleas  are  concerned  in  the  transmission. 
The  germ  is  very  resistant,  and  will  live  for  at  least 
eighty  days  in  dust,  and  for  a  period  of  a  month  in  either 
fresh  or  salt  water.  However,  it  has  never  been  found  nat- 
urally in  dust  or  water,  but  it  has  been  found  in  10  per 
cent,  of  the  goats  examined  in  Malta.  The  animals  are 
apparently  quite  healthy,  although  occasionally  chronic  mas- 
titis may  be  noted.  The  disease  appears  to  be  conveyed  to 
man  by  milk  of  infected  goats,  and  generally  disappears  when 
milk  is  rendered  safe.  Other  methods  of  infection,  however, 
are  suspected.  It  has  been  assumed  that  it  may  be  spread 
through  the  respiratory  system  by  inhaling  dust  which  has 
been  contaminated  by  goats'  urine,  and  also  through  abra- 
sions, wounds  or  cuts.  The  method  of  spread  from  goat  to 
goat  is  not  known.  Exceedingly  minute  quantities  of  a  cul- 
ture are  necessary  to  infect.  The  prick  of  a  contaminated 
needle  is  sufficient.  Infection  is  reported  to  have  taken  place 
through  using  a  clinical  thermometer  in  a  country  not  known 
to  be  infected,  by  placing  it  in  the  mouth  of  a  healthy  sub- 
ject after  it  had  been  used  by  a  new  arrival  sufifering  with  the 
disease.  Persons  between  6  and  30  years  of  age  are  most 
susceptible.  Long  residence  in  an  endemic  area  is  said  to 
confer  no  immunity. 

The  micrococcus  enters  the  system  through  the  aliment- 
ary tract  and  causes  septicemia.  Enlargement  of  the  spleen 
is  a  marked  feature.  This  causes  the  disease  at  times  to  be 
mistaken  for  typhoid  fever.  Ross  and  Eyre^o  believe  that  the 
micrococcus  may  be  conveyed  by  mosquitoes,  but  definite 
proof  is  lacking.  Bruce^^  believes  that  one  attack  confers 
immunity.     Other  clinicians  have  expressed  great  doubt. 


MALTA    FEVER.  253 

The  spleen  is  enlarged  and  may  weigh  as  much  as  400 
grams  (14.1  oz.).  It  is  soft  and  shows  an  increase  of 
lymphoid  cells.  There  is  congestion  of  the  liver,  kidneys  and 
other  abdominal  organs.  The  colon  may  1)e  ulcerated,  espe- 
cially if  there  has  been  hemorrhage.  The  lungs  are  congested, 
and  may  show  patches  of  consolidation. 

Monkeys  fed  with  infected  milk  require  an  incubation 
period  of  fifteen  days ;  human  beings,  according  to  Johnstone, 
fourteen  days.  Cases  occur  with  an  apparent  incubation 
period  as  low  as  six  days.  The  onset  of  the  disease  is  grad- 
ual. The  patient  usually  continues  at  work,  although  he  has 
a  fever.  The  temperature  rises  gradually,  and  the  clinical 
symptoms  are  much  the  same  as  in  typhoid.  After  a  few 
days  severe  pains,  often  thought  to  be  rheumatic,  occur  in 
the  back  and  limbs.  Headaches  become  intense,  and  there  is 
almost  complete  loss  of  appetite.  The  temperature  by  this 
time  is  usually  three  or  four  degrees  above  normal,  and  the 
pyrexia  is  often  accompanied  by  slight  sore  throat  and  ten- 
derness in  the  epigastric  region.  There  may  also  be  bronchial 
catarrh  and  congestion  of  the  lungs.  These  symptoms  con- 
tinue for  a  number  of  weeks.  The  temperature  remains  con- 
tinuously high,  varying  from  103°  to  105°  F.  (39.5°  to  40.5° 
C),  but  after  several  weeks  it  may  decline,  and  the  patient 
feels  somewhat  better.  In  a  few  days  a  relapse  occurs  and 
the  same  symptoms  reappear.  This  relapse  may  continue  as 
long  as  the  original  fever,  but  it  is  usually  of  somewhat 
shorter  duration.  One  relapse  follows  another,  and  the  illness 
may  extend  over  a  period  of  many  months.  After  that  the 
temperature  becomes  undulating,  with  marked  rise  at  night 
and  fall  in  the  morning.  The  patient  becomes  anemic  and 
weak.  The  alimentary  canal  becomes  irritated,  and  there  is 
indigestion,  which  may  be  accompanied  by  constipation  or 
diarrhea.  Often  the  gums  become  spongy  and  bleed  on  pres- 
sure. The  spleen  is  enlarged  and  painful.  The  patient  feels 
miserable,  and  has  headache  and  pains  all  over  the  body. 
Insomnia  and  hysterical  outbreaks  are  not  uncommon.  x\cute 
delirium  is  rare.  The  skin  is  usually  damp.  Perspiration  of 
a  peculiar  disagreeable  odor,  profuse  in  character,  occurs  from 
the  beginning.  It  is  generally  worse  in  the  morning.  Suda- 
mina  generally  occur  after  the  third  week.     Sometimes  the 


254  TROPICAL  DISEASES. 

joints  become  swollen  and  painful,  but  the  skin  with  which 
they  are  covered  seldom  is  reddened.  The  hip-,  shoulder-, 
ankle-,  and  knee-  joints  are  most  commonly  affected.  The 
blood  shows  a  secondary  anemia,  with  a  loss  of  20  to  40  per 
cent,  of  corpuscles.  There  is  a  marked  reduction  of  hemo- 
globin and  some  poikilocytosis.  Phagocytic  power  is  dimin- 
ished, as  well  as  bactericidal  properties.  The  blood  findings 
lead  Bassett-Smith^s  to  the  opinion  that  an  attack  does  not 
confer  immunity.  One  of  the  best  diagnostic  signs  upon 
which  to  rely  is  the  agglutination  which  takes  place  in  dilu- 
tions of  1  in  50  within  about  thirty  minutes.  The  urine  is 
that  of  a  typical  fever  case,  with  the  exception  that  there  is 
seldom  albumin  or  granular  casts.  The  specific  germ  of  the 
disease  sometimes  can  be  found  in  the  urine  two  years  after 
an  attack.  The  patient  now  becomes  extremely  anemic  and 
prostrated  by  the  repeated  attacks  of  fever.  When  improve- 
ment sets  in  the  intermissions  between  the  febrile  attacks 
increase  until  recovery  takes  place.  The  tongue  clears  and 
the  remaining  symptoms  abate.  Convalescence  may  begin 
after  the  twentieth  day,  or  sometimes  the  fever  may  last 
nearly  a  year.  The  average  period  is  three  months.  A  num- 
ber of  varieties  have  been  described  by  some  authors.  In  the 
malignant  type,  which  comes  on  suddenly,  with  a  temperature 
of  104°  to  105°  F.  (40°  to  40.5°  C),  practically  all  of  the 
symptoms  occur  which  have  been  described  before,  in  a  much 
shorter  period  and  in  an .  aggravated  form.  In  the  intermit- 
tent variety  the  onset  is  very  slow,  and  the  remissions  are  of 
longer  duration.  There  is  an  ambulatory  type,  in  which  the 
patient  is  not  aware  that  he  is  sufifering  with  any  complaint, 
and  often  gives  positive  blood  reactions  for  the  disease  over 
long  periods  of  time.  There  has  also  been  a  para-Malta  fever 
described,  which  is  attributed  to  the  Micrococcus  parameli- 
tensis  of  Negre  and  Raynaud. -^  This  is  not  a  well-recognized 
entity. 

Ulcers  provoking  hemorrhage  in  the  small  and  large  intes- 
tines are  complications  of  real  gravity,  and  at  times  extreme 
hyperpyrexia,  pneumonia,  pleuritic  effusion  and  cardiac  fail- 
ure are  observed.     Orchitis  is  common. 

Neurasthenia,  with  its  long  train  of  symptoms,  is  prob- 
ably one  of  the  commonest  sequelae  of  the  disease. 


MALTA    FEVER.  255 

The  principal  clinical  signs  upon  which  to  base  a  diag- 
nosis are  the  prolonged  character  of  the  fever,  the  profuse 
sweating  and  the  joint  symptoms.  Bacteriology  furnishes  a 
practically  positive  method  of  recognizing  the  disease,  and  is 
more  dependable  than  the  attempt  to  make  a  differential 
clinical  diagnosis.  Clinically,  there  is  great  resemblance  to 
typhoid  fever  during  the  first  and  second  weeks.  Widal's 
reaction  or  blood-cultures  will  distinguish  typhoid.  Kala-azar 
also  resembles  Malta  fever,  but  the  typical  blood-parasite  is 
a  sufficient  differentiating-  sign. 

The  prognosis  is  usually  good.  The  mortality  may  be  as 
low  as  2  per  cent,  in  some  outbreaks,  but  at  times  it  rises  to 
13  per  cent. 

TREATMENT. 

The  treatment  is  symptomatic,  and  the  use  of  vaccines  and 
serums  has  not  been  successful.  New  serums  are  being  con- 
stantly tried,  and  at  times  some  of  these  appear  to  be  of  value, 
but  so  far  they  have  not  stood  a  prolonged  test.  Excellent 
nursing  is  an  essential.  It  is  also  desirable  that  the  patient 
be  kept  in  a  screen-proof  room  or  under  a  mosquito-net.  Pre- 
caution should  also  be  taken  to  disinfect  the  stools  and  the 
urine,  as  well  as  the  other  discharges.  Open  abrasions  in 
attendants  should  be  sealed.  Headaches  may  be  relieved  by 
acetanilid,  but  at  times  morphin  is  necessary.  The  joint 
symptoms  may  be  treated  by  hot  fomentations  or  with  bella- 
donna and  opium  applications.  The  bowels  should  be  reg- 
ulated, and  at  the  beginning  of  the  attack  fractional  doses  of 
calomel  should  be  given  until  free  purgation  is  produced. 
Mouth-washes  of  mild  antiseptics  should  be  regularly  em- 
ployed. Sponging  to  keep  down  the  temperature  is  important. 
Briefly,  the  nursing  and  treatment  should  be  much  the  same 
as  in  typhoid  fever.  During  convalescence  tonics  are  indi- 
cated.    During  fever  periods  the  diet  should  be  liquid. 

Prophylaxis.  Successful  prophylaxis  of  Malta  fever,  in 
accordance  with  the  experience  at  Gibraltar,  can  be  insured 
by  abstaining  from  the  use  of  goats'  milk,  and  precautions  to 
avoid  this  should  be  taken.  In  endemic  countries  residents 
should  be  careful  to  use  only  milk  that  has  been  boiled. 


256  TROPICAL   DISEASES. 

CHOLERA. 

Asiatic  cholera  is  an  acute  infectious  disease  caused  by 
the  vibrio,  of  Koch,  and  is  characterized  by  violent  purging, 
vomiting,  muscular  cramps,  suppression  of  urine,  husky  voice 
and  collapse. 

The  true  origin  of  the  name  Cholera  probably  comes  from 
two  Hebrew  words,  Choli-ra  (or  morbus  mains). 

Among  the  several  synonyms  applied  to  this  infection  are 
included  Cholera  Asiatica,  Pestilential  Asphyxia,  Morbus 
Asiaticus,  Morbus  Oryzeus  (ascribed  by  Tytler  to  damaged 
rice),  Haiza  (Hindustani),  Enerum  Vandee  (Tamil),  Ho- 
louan  (Chinese),  Duba  (Arabic). 

Cholera  is  endemic  in  certain  parts  of  India,  and  probably 
in  China,  Japan,  Java  and  in  the  Philippines.  It  is  also  not 
unlikely  that  the  disease  is  endemic  in  certain  sections  of  the 
Balkans  and  the  nearby  Russian  territory.  In  the  past  it  has 
been  assumed  that  the  disease  has  advanced  out  of  India  and 
caused  worldwide  epidemics  which  have  been  responsible  for 
a  large  loss  of  life.  However,  it  now  seems  probable  that  the 
cholera  carrier  is  an  important  reservoir  of  the  disease,  and 
that  the  carrier  is  not  necessarily  confined  to  India.  The 
old  views  that  cholera  remained  indefinitely  alive  in  certain 
water  supplies  similar  to  those  of  the  Ganges  is  not  tenable, 
although  it  is  quite  probable  that  the  vibrio  may  remain 
alive  in  certain  water  for  many  months.  The  spread  of  the 
disease  is  always  along  the  line  of  travel.  It  is  probably 
carried  in  the  intestines  of  the  human  beings,  and,  perhaps, 
to  a  lesser  extent  in  the  food  and  water  supplies  which  are 
used  for  human  consumption.  It  is  primarily  a  disease  of  the 
human  intestines,  and  it  is  probably  never  contracted  except 
by  the  introduction  of  the  specific  micro-organism  into  the  mouth. 
One  of  the  first  reasonable  authentic  records  shows  that 
cholera  advanced  out  of  India  in  1817.  [There  is  small  doubt 
that  the  disease  occurred  in  epidemic  form  long  before  this.] 
Epidemic  cholera  has  always  followed  the  line  of  travel.  There 
are,  however,  many  instances  of  cholera  appearing  simultane- 
ously over  widely  separated  areas  without  its  having  been 
possible  to  trace  any  connection  between  cases.  These  obser- 
vations, however,  are  confined  to  countries  in  which  cholera 


CHOLERA.  257 

is  endemic.  Mention  is  made  of  the  disease  in  manuscript 
and  in  ancient  Chinese  writings,  but  in  view  of  the  absence 
of  accurate  descriptions  and  the  similarity  which  may  exist 
between  many  of  the  intestinal  diseases,  too  much  reliance 
cannot  be  placed  on  these  older  writings.  For  instance,  in 
London  an  outbreak  of  the  disease  was  described  by  Willies 
in  1670  which  he  called  dysenteria  acuta  epidemica.  Cholera 
has  appeared  in  epidemic  form  in  recent  times  during  five 
different  periods  (1830,  1846,  1865,  1884,  1892),  and  has  been 
more  or  less  continuously  present  in  some  parts  of  Europe 
from  1910  to  1916.  In  1910  cholera  was  transmitted  from 
Russia  to  Bari  in  Italy,  and  from  there  it  spread  through 
Southern  Europe.  In  1914  cholera  spread  among  the  Aus- 
trian troops  engaged  in  the  European  war;  cases  have  been 
reported  even  in  Vienna  and  Prague.  In  1906  and  1907  cholera 
was  carried  to  Hamburg  by  emigrants  from  Russia.  Probably 
the  greatest  distributor^  of  cholera  are  through  the  pilgrim- 
ages which  Mohammedans  from  all  over  the  world  make  to 
Mecca.  The  crude  conditions  under  which  they  travel,  the 
inadequate  human  excrement  disposal  en  route  and  at  Mecca, 
favors  the  propagation  of  the  disease.  From  Mecca  it  is  again 
carried  by  the  same  pilgrims  to  their  home  countries.  In 
1865  cholera  was  carried  to  New  York  from  ports  in  the 
Levant,  probably  via  London,  by  the  English  ship  Atlanta, 
which  left  London,  October  10th,  with  a  cargo  of  merchandise 
and  forty  persons.  On  October  11th  the  vessel  reached 
Havre,  where  it  remained  one  day,  and  embarked  564  new 
passengers,  who  had  passed  throug-h  Paris,  where  they  had 
remained  some  days,  and  where  cholera  was  prevailing  in 
epidemic  form.  One  day  out  from  Havre  there  was  a  death 
from  cholera  in  a  child  which  came  from  the  Weissen  Lamm 
Hotel  of  Paris.  Five  other  deaths  followed  in  the  succeeding 
five  days  in  a  family  that  had  stayed  in  the  hotel  Huitgar-/ 
derhof  of  Paris.  On  arrival  of  the  Atlanta  in  New  York,  the 
surgeon  declared  60  cases  of  cholera  and  15  deaths  during  the 
voyage.  The  vessel  was  placed  in  a  strict  quarantine,  and 
no  cholera  appeared  in  the  United  States  during  that  year. 
In  the  early  sixties  cholera  was  imported  into  Quebec,  and 
from  there  spread  rapidly  to  the  United  States,  and  caused 
many  deaths,  particularly  in  Ohio.     In  September,  1892,  10 

17 


258  TROPICAL   DISEASES. 

cases  with  8  deaths  occurred  in  New  York,  and  were  traced 
to  infection  imported  from  Hamburg;  7Z  cases  with  43  deaths 
occurred  in  the  harbor.  In  1893  there  were  20  cases  and  4 
deaths  in  the  harbor;  1  death,  which  was  confirmed  by  bac- 
teriologic  examination,  occurred  in  Jersey  City,  but  the  dis- 
ease did  not  gain  a  foothold  in  the  United  States,  In  1911 
almost  every  ship  with  immigrants  arriving  in  the  harbor 
from  the  Mediterranean,  between  the  first  of  July  and  the 
first  of  September,  had  cases  of  cholera  or  cholera  carriers 
aboard ;  2  cases  attributed  to  infected  ships  were  found  in 
Brooklyn,  and  1  in  Auburn,  New  York.  More  than  seventeen 
days  had  elapsed  in  these  cases  since  last  exposure  to  a 
known  case  of  cholera.  There  was,  however,  much  evidence 
that  there  were  many  cholera  carriers  on  board  the  vessels 
from  which  the  Brooklyn  cases  came.  During  August,  1911, 
2  cases  of  cholera  occurred  in  Boston,  1  in  an  Irish-American 
who  had  been  a  permanent  resident  of  Boston,  and  no  con- 
tact with  cholera  cases  could  be  established.  The  other  case 
occurred  in  an  Italian  woman  who  had  been  a  permanent 
resident  of  Boston  for  a  number  of  months,  and  had  not  been 
exposed  to  cholera.  The  diagnosis  in  the  case  of  the  Irish- 
American  was  bacteriologically  confirmed  by  the  city  health 
department  and  the  bacteriologic  laboratory  of  the  United 
States  Public  Health  Service.  It  is  quite  likely  that  cholera 
is  transmitted  from  place  to  place  and  from  one  country  to 
another,  principally  by  the  means  of  the  human  intestinal  dis- 
charges finding  their  way  directly  or  indirectly  through  food 
or  water  to  the  mouths  of  other  individuals. 

A  severe  outbreak  of  cholera  began  in  the  Philippines  dur- 
ing March,  1902,  and  continued  until  April,  1904,  during 
which  time  166,252  cases  and  109,461  deaths  occurred.  The 
origin  of  this  epidemic  has  been  attributed  to  an  importation 
of  infected  cabbages  from  Hong  Kong.  It  is  more  than 
likely,  however,  in  view  of  the  present  knowledge,  that  in 
spite  of  the  rigid  five-day  quarantine  which  was  imposed 
against  Hong  Kong,  where  cholera  had  prevailed  for  some 
weeks  previous  to  its  appearance  in  the  Philippines,  the  dis- 
ease was  probably  introduced  by  a  cholera  carrier.  It  is  also 
of  interest  to  note  that  the  disease  made  its  appearance  sim- 
ultaneously in  Manila  and  in  Nueva  Caceres,  which  is  three 


CHOLERA.  259 

days'  steaming  distance  from  Manila.  In  August,  1905,  the 
disease  again  reappeared  and  lasted  until  April,  1907,  during 
which  time  13,429  cases  and  10,093  deaths  occurred.  It  again 
appeared  in  July,  1907,  after  an  absence  of  only  two  months, 
being  present  until  March,  1911,  with  a  total  of  50,871  cases 
and  33,792  deaths;  was  absent  from  April  through  June,  1911 ; 
and  again  present  from  July  through  October,  1911,  with  50 
cases  and  43  deaths.  From  November,  1911,  through  July, 
1913  (a  3^ear  and  nine  months),  no  cases  of  cholera  were 
reported  in  the  islands,  but  in  August,  1913,  the  disease  again 
appeared,  lasting  through  March,  1914,  with  a  total  of  1093 
cases  and  780  deaths;  from  April  through  June,  1914,  being 
responsible  to  date  (January  26,  1915)  for  3004  cases  and 
2041  deaths. 

There  is  considerable  evidence  to  show  that  the  disease 
prevails  in  similar  epidemic  form  in  Java,  the  Straits  Settle- 
ments, Japan,  and,  to  a  more  limited  extent,  in  China.  The 
small  number  of  cases  in  China  is,  in  all  probability,  due  to 
the  great  value  of  human  excrement  as  an  insecticide  and 
fertilizer,  which  makes  its  immediate  collection  of  great  com- 
mercial advantage ;  and  also  to  the  fact  that  the  Chinese  do 
not  eat  with  their  fingers,  and  almost  invariably  drink  boiled 
water,  in  the  form  of  tea,  and  eat  almost  all  of  their  vege- 
tables in  a  cooked  state.  There  is  considerable  reason  to 
believe  that,  on  account  of  the  other  filthy  habits  of  the 
Chinese,  if  they  did  not  have  the  foregoing  customs,  the 
ravages  of  cholera  in  that  country  would  be  frightful.  In 
Japan  the  same  value  is  placed  upon  human  excrement  as  in 
China,  but  the  Japanese  drink  much  unboiled  v^^ater  and  eat 
many  contaminated  vegetables  in  a  raw  state. 

It  is  likely  that  cholera  microbes  may  be  transported  in 
water  or  foodstuffs  which  act  as  a  suitable  media.  That 
cholera  may  be  transported  by  healthy  individuals  who  act 
as  carriers  has  now  been  proved.  During  the  cholera  out- 
break in  ]\Ianila,  in  1911,  McLaughlin  showed  that  5  per  cent, 
of  the  prisoners  of  Bilibid  were  cholera  carriers,  although 
none  of  them  had  been  exposed  to  the  disease.  In  August, 
1916,  there  were  over  150  cholera  carriers  in  Bilibid  Prison, 
but  no  true  case  of  cholera  occurred.  The  diagnosis  in  each 
instance  was  bacteriologically  confirmed  by  -Schobel,  of  the 


260  TROPICAL   DISEASES. 

Bureau  of  Science  Laboratory.  Cholera  carriers  were  de- 
tected in  Bilibid  Prison  for  a  number  of  months  prior  to 
August,  which  corresponds  to  the  period  in  which  cases  of 
cholera  were  constantly  occurring-  among  the  residents  of 
Manila.  So  far  as  known,  there  was  no  contact  of  these  pris- 
oners with  infected  cases  outside  of  the  prison. 

Cholera  also  may  be  transmitted  by  animals.  In  1914, 
Barber,30  of  the  Bureau  of  Science  at  Manila,  showed  that 
cockroaches  which  fed  on  human  cholera  feces  may  harbor 
cholera  vibrios  in  their  intestines,  and  that  they  may  occur 
in  enormous  numbers  in  the  insects'  feces  for  at  least  two 
days  after  the  last  feeding.  It  is,  therefore,  apparent  that, 
by  means  of  feces  and  vomited  matter,  cockroaches  may  act 
as  carriers  of  cholera  to  human  food.  Barber  also  showed 
that  cholera  vibrios  from  cockroaches'  feces  would  survive  on 
a  pie,  for  instance,  for  at  least  sixteen  hours  after  being 
deposited. 

Also  that  cholera  vibrios  in  human  feces,  when  placed  on 
food  in  competition  with  other  bacteria,  will  survive  for  at 
least  four  days.  He  also  found  cholera  vibrios  in  the  bodies 
of  ants  at  least  eight  hours  after  they  had  ingested  cholera 
cultures  which  had  been  placed  on  human  feces.  The  more 
probable  routes  by  which  cholera  germs  find  their  way 
from  infected  human  intestines  to  the  gastro-intestinal  tract 
of  other  individuals  probably  are  as  follows :  In  widespread 
epidemics  probably  through  the  infection  reaching  the  water 
supplies,  and  in  more  restricted  outbreaks  probably  through 
the  micro-organism  reaching  the  food  by  the  means  of  infected 
hands,  or  by  flies,  or  other  insects.  There  is  an  authentic 
case  on  record  in  which  flies  transmitted  the  disease  to  the 
nursing  bottle  of  an  infant.  Cultures  have  been  made  from 
the  feet  of  flies  which  had  come  in  contact  with  infected 
human  excrement.  There  are  instances  on  record  where 
whole  rivers  have  become  infected,  and  the  disease  spread 
down  these  rivers  to  people  who  used  the  water.  It  should 
also  be  remembered  that  there  are  instances  in  which  the 
disease  has  spread  up  rivers.  This  is  explained  by  cholera 
carriers.  The  theories  of  Pettenkofer,  that  the  vibrio  is 
])ropagated  in  the  soil,  and  that  an  outbreak  of  the  disease  is 
intimately  connected  with  the  rise  and  fall  of  subsoil  water, 


CHOLERA.  261 

are  not  tenable,  and  lack  adequate  data  for  their  clear  proof. 
Cholera  is  mostly  a  disease  of  warm  countries,  although  very 
severe  outbreaks  have  occurred  in  countries  of  the  temper- 
ate zones,  but  this  usually  took  place  in  the  summer  time, 
when  the  conditions  were  tropical.  It  is  more  than  likely  that 
the  reason  why  the  disease  does  not  spread  during-  the  winter 
period  in  the  temperate  zones  is  the  fact  that  cold  weather 
is  inimical  to  the  growth  of  cholera  vibrios  in  the  human 
feces  after  they  have  left  the  body,  and  there  is,  in  conse- 
quence, less  opportunity  for  the  infection  to  be  spread  by 
insects  or  hands. 

Strictly  speaking-,  cholera  cannot  be  said  to  be  a  race  dis- 
ease, although  in  Manila,  for  instance,  the  statistics  show  that 
one  Chinaman  out  of  7000  contracted  the  disease,  whereas  one 
Filipino  out  of  300  became  infected.  This  is  doubtless  due 
to  the  personal  habits  of  the  two  races;  a  Chinaman,  for 
instance,  practically  never  drinks  water  except  in  the  form 
of  boiled  tea,  and  uses  cooked  food  which  he  eats  with  chop- 
sticks. A  Filipino  drinks  unboiled  water,  and  eats  his  food, 
much  of  it  uncooked,  with  his  fingers,  thereby  affording  an 
excellent  opportunity  for  a  cholera  carrier  to  transmit  the  in- 
fection to  the  common  bowl  which  serves  so  frequently  as  a 
receptacle  from  which  two  or  more  persons  dip  with  their 
fingers  to  partake  of  their  food. 

Cholera  is  caused  by  the  vibrio  of  Koch,  although  the 
presence  of  this  micro-organism  in  the  human  intestines  does  not 
necessarily  mean  that  the  individual  has  or  has  had  cholera. 
It  is  has  now  been  well  demonstrated  that  many  persons,  espe- 
cially in  districts  in  which  cholera  prevails,  harbor  cholera 
vibrios,  but  do  not  have  the  disease.  This  fact  has  become 
so  generally  recognized  that  literature  of  the  present  day 
fairly  teems  with  the  question  of  cholera  carriers.  There  are 
instances  on  record  in  which  organisms  identical  with  the 
cholera  vibrios  have  been  found  in  the  stools  of  persons  who 
are  residents  of  the  Mississippi  Valley  in  the  United  States. 
In  some  of  these  areas  it  can  be  said  wnth  reasonable  cer- 
tainty that  no  cholera  has  occurred  for  more  than  twenty 
years.  Another  interesting  phase  of  the  question  concerns 
the  sudden  appearance  of  cholera  in  communities,  without  its 
being  possible   to   trace   the   infection   to   known   centers   of 


262  TROPICAL    DISEASES. 

cholera.  This  fact  has  frequently  been  observed  in  Manila, 
and  very  extensive  investigations  have  been  made  to  trace 
the  infection  to  an  outside  source,  but  without  success.  In 
1914  it  was  thought  desirable  in  Manila  to  examine  for 
cholera  vibrios  the  stools  of  persons  who  had  been  discharged 
as  cured  from  the  cholera  hospital  the  year  previous.  In  the 
first  fifty  examinations  made,  an  active  cholera  carrier  was 
found.  He  was  employed  as  a  waiter  in  a  restaurant,  and  his 
record  showed  that  he  had  been  discharged  from  the  cholera 
hospital  seven  months  previously,  and  only  after  two  nega- 
tive stool  examinations  had  been  reported.  About  a  month 
after  the  discovery  of  this  case  cholera  suddenly  reappeared 
in  Manila.  There  have  been  also  outbreaks  of  cholera  in 
Manila  which  were  preceded  by  deaths  suspicious  of  cholera, 
but  in  which  it  was  impossible  to  demonstrate  the  cholera 
vibrio.  These  cases  usually  died  with  an  intense  nephritis, 
evidently  of  toxic  origin,  the  exact  source  of  which  could  not 
be  traced. 

Some  authors  have  attempted  to  explain  outbreaks  of 
cholera  on  the  basis  that  cholera  vibrios  are  more  or  less 
normally  present  in  the  human  intestines,  and  that  mental 
worry  and  other  depressing  factors  may  so  reduce  the  vitality 
of  the  subject  that  the  germs  are  able  to  overcome  the 
defenses  of  nature  and  cholera  results.  An  explanation  of 
that  kind  is  unsatisfactory.  An  explanation  that  is  more 
sound,  although  unproved,  is  that  there  is  a  change  in  the 
morphology  of  the  micro-organism,  and  that  during  certain  cycles 
the  vibrio  is  non-infective.  Also  that  the  micro-organism  becomes 
so  attenuated  as  to  be  non-infective,  and  that  it  is  only  by 
the  passage  through  one  or  more  human  intestines  that  it 
attains  sufficient  virulence  to  be  infective ;  thus  conditions 
arise  that  are  then  favorable  for  an  outbreak  of  cholera. 

Cholera  is  directly  transmissible  from  man  to  man.  An 
example  of  this  form  of  transmission  is  well  illustrated  by 
doctor  or  nurse  whose  hands  come  in  contact  with  the  dis- 
charges of  a  cholera  case,  and  who  then  partakes  of  food 
without  disinfecting  the  hands,  the  penalty  of  this  gross 
delinquency  being  a  typical  attack  of  the  disease.  Great  epi- 
demics are  probably  caused  by  the  water  supply  becoming 
infected  with  cholera-infected  human  excrement.     A  classic 


CHOLEIL\.  263 

instance  of  water  infection  is  that  of  the  London  Pump,  in 
1854,  when  the  well  became  infected,  and  persons  who  used 
the  water  contracted  the  disease.  In  1892  the  cholera  out- 
break in  Hamburg  was  confined  to  persons  who  used  the 
unfiltered  water  of  the  Elbe.  Those  who  used  the  filtered 
water  escaped.  The  micro-organism  was  found  in  the  river  and 
in  the  tap-water.  In  1911,  at  Cebu,  a  real  "nest"  of  cholera  was 
traced  to  an  infected  well ;  several  Americans  and  a  great 
number  of  Filipinos  who  used  water  from  the  well  lost  their 
lives.  Milk  is  frequently  an  important  source  of  infection  by 
being  diluted  with  cholera-infected  water,  and,  once  contami- 
nated, it  makes  an  excellent  media  for  the  growth  of  cholera 
vibrios.  Great  epidemics  are  caused  by  extensive  water  or 
food  infection.  The  hands  of  persons  who  come  in  contact 
with  cholera  stools  and  then  handle  food  are  a  great  factor 
in  the  dissemination  of  cholera.  The  human  cholera  carrier 
is  also  a  very  important  factor,  especially  since  he  introduces 
the  vibrio  into  many  places  in  which  its  presence  is  not 
suspected.  It  must  also  be  remembered  that  cholera  germs 
can  live  in  water  under  favorable  conditions  for  more  than 
one  hundred  days,  and  that  they  have  been  reported  to  have 
remained  alive  in  human  feces  for  a  period  of  one  hundred 
and  sixty-three  days.  Cholera  always  follows  the  routes  of 
travel,  whether  by  human,  ships,  rivers,  roads,  railways,  or 
other  means  of  communication.  It  is  also  of  importance  to 
draw  attention  to  the  fact  that  spirilla  resembling  cholera 
vibrios  are  frequently  found  in  human  discharges,  and  that  it 
is  only  by  careful  cultivation  and  agglutination  tests  that  the 
cholera  vibrio  can  be  definitely  identified. 

Until  quite  recently  it  was  believed  that  the  cholera  vibrios 
could  be  found  only  in  the  intestine,  and  that  the  symp- 
toms and  the  effects  of  the  disease  were  due  to  the  production 
of  an  endocellular  toxin.  Grieg^i  has  lately  demonstrated  the 
presence  of  the  cholera  vibrio  in  the  spleen,  but  up  to  the 
present  time  it  has  not  been  possible  to  state  whether  the 
vibrios  outside  of  the  human  intestines  are  connected  with 
the  symptomatology. 

In  general,  however,  it  may  be  stated  that  the  vibrio 
occurs  abundantly  in  the  glands  and  the  epithelial  cells  and 
mucosa  of  the  small  intestine.     It  is  presumed  that  an  endo- 


264  TROPICAL   DISEASES. 

toxin  which  is  set  free  causes  the  gastro-intestinal  disturbance 
which  is  responsible  for  the  passage  of  fluid  from  the  blood 
into  the  bowel.  Analyses  show  this  at  first  to  consist  of 
water,  then  sodium  chlorid  and  other  inorganic  salts,  still 
later  phosphate  and  potassium  salts,  and  finally  organic  sub- 
stances. The  fact  that  water  is  found  first  would  indicate 
that  the  process  is  not  an  endosmosis.  It  may  be  a  secretion. 
At  all  events,  it  causes  great  concentration  of  the  blood,  the 
specific  gravity  of  which  may  reach  to  1.078.  In  this  concen- 
trated form  sometimes  as  many  as  8,000,000  erythrocytes  per 
cubic  millimeter  are  found.  There  is  a  marked  fall  in  the 
blood-pressure,  which  may  decline  to  as  low  as  50  millimeters 
of  mercury  (systolic).  The  urine  is  generally  suppressed  or 
scanty,  with  high  specific  gravity,  albumin,  casts,  and  an 
increase  in  the  amount  of  indican. 

As  a  rule,  the  post-mortem  rigidity  is  marked.  It  some- 
times happens  that  bodies  dead  of  cholera  change  position; 
sometimes  they  rise  to  the  sitting  posture,  or  are  even  thrown 
from  the  table  by  severe  muscular  contractions.  Occasionally 
contractions  which  force  air  out  of  the  lungs  produce  sounds 
which  strike  terror  into  the  hearts  of  those  who  are  not 
familiar  with  the  cause  of  their  production. 

On  cutting  the  tissues  it  is  noticed  that  they  are  very  dry, 
and  that  the  blood  is  frequently  thick  and  tarry  in  appear- 
ance. On  opening  the  peritoneal  cavity  a  sticky  sensation  is 
imparted  to  the  hand  when  it  is  passed  among  the  loops  of 
the  intestines.  This  is  usually  very  characteristic,  and  is 
peculiar  to  cholera.  The  stomach  nearly  always  contains 
fluid,  and  when  death  has  been  sudden  it  may  contain  food. 
The  intestines  are  reddish  in  appearance,  and  there  are  often 
small  punctiform  hemorrhages.  The  reddish  appearance, 
however,  is  not  specially  characteristic,  and  is  much  the  same 
as  seen  in  other  conditions.  The  contents  of  the  intestines 
^re  usually  found  to  be  a  whitish  turbid  liquid,  very  much 
Jike  the  sauce  commonly  used  for  cottage  pudding,  but  some- 
what thinner.  Often  it  contains  small  whitish  flakes,  and  on 
microscopic  examination  is  found  to  consist  of  food  particles, 
epithelial  cells,  red  and  white  blood-corpuscles,  mucus  and 
micro-organisms.  The  mucosa  of  the  stomach  and  intestines 
is  generally  hyperemic  and  swollen,  and  may  be  marked  with 


CHOLERA.  265 

r.umeroiis  punctiform  hemorrhages.  The  villi  are  swollen, 
giving-  the  surface  a  dull,  opaque,  translucent  appearance,  and 
Payer's  patches  and  the  solitary  follicles  are  much  enlarged. 
The  ilium  and  the  upper  end  of  the  large  intestine  appear  to 
be  studded  with  cooked  sago-like  grains.  In  the  lower  bowel 
there  are  usually  large  quantities  of  the  turbid  whitish  fluid 
described  above,  but  if  death  has  been  due  to  cholera  sicca 
the  stools  are  usually  hard  and  firm,  and  cholera  flakes  are 
rare.  The  glands  of  the  stomach  and  duodenum  are  enlarg^ed, 
and  the  surface  is  denuded  of  epithelium.  There  are  no  spe- 
cial lesions  of  other  organs.  The  liver  is  seldom  enlarged, 
and  only  rarely  does  it  show  moderate  cloudy  swelling.  The 
spleen  is  usually  normal,  but  may  be  small,  hard,  and 
wrinkled  upon  its  surface,  and  deep  red  upon  section.  The 
kidneys  have  a  characteristic  deep-red  and  opaque  appear- 
ance, this  change  being  most  marked  in  cases  in  which  anuria 
was  present  some  days  before  death.  The  heart  is  usually 
soft  and  flabby,  and  the  muscles  degenerated.  In  cases  in 
which  death  has  been  rapid  there  are  frequently  ecchymoses 
on  the  surface  of  the  endo-  and  peri-  cardium.  In  cases  which 
have  been  ill  over  three  days  there  may  be  evidences  of 
cholera  pneumonia.  Microscopically,  the  cholera  vibrios  may 
be  seen  in  Lieberkuhn's  follicles,  in  the  epithelial  cells,  and 
in  the  mucosa  of  the  intestine  and  the  stomach.  Rebulski 
and  Grieg32  have  recorded  cases  in  which  the  vibrio  was  found 
in  the  liver,  spleen  and  heart. 

Spirillum  of  Cholera.  The  cholera  vibrio  was  discovered 
by  Koch^3  j^  1883  in  Egypt,  and  he  confirmed  his  work  the 
following  year  in  India.  In  the  intestines  and  dejecta  the 
organism  presents  the  appearance  of  a  short  thick  rod  slightly 
curved  in  the  long  diameter.  It  is  about  half  as  long  and 
twice  as  thick  as  the  tubercle  bacillus.  The  cholera  vibrio  is 
0.8  to  3  microns  in  length,  and  0.3  to  0.5  microns  in  breadth.  It 
is  generally  found  singly,  but  it  may  be  arranged  in  pairs  with 
the  curves  opposite  to  each  other,  in  which  event  it  may  re- 
semble the  letter  S.  A  simple  microscopic  examination  of  a 
smear  preparation  is  not  sufficient  to  estal)lish  or  to  exclude 
a  diagnosis.  It  very  often  happens  that  curved  spirilla 
cannot  be  found  in  smear  preparations,  but  nevertheless  they 
may  be  recovered  by  culture.     The  motility  is  very  charac- 


266  TROPICAL   DISEASES. 

teristic,  and  has  been  demonstrated  by  .Lofifier  to  be  due  to 
fine  celia  which  are  longer  than  the  bacteria,  and  are  attached 
to  one  end  of  the  micro-organism.  Many  different  methods  for 
the  bacteriologic  diagnosis  of  cholera  have  been  devised.  The 
method  used  by  Schobel  and  other  workers,  used  many  thou- 
sand times  at  the  Bureau  of  Science  in  Manila,  has  proved 
reliable,  quick  and  practical : 

"The  stool  specimen,  which  is  collected  with  a  sterile  glass 
tube,  is  placed  into  a  tube  containing  a  slightly  alkaline  1  per 
cent,  peptone  solution.  This  is  incubated  for  some  twelve  to 
twenty  hours,  and  then  transplanted  to  Dieudonnes  plates. 
On  these  plates  practically  no  other  organisms  are  found 
except  those  of  cholera,  and  the  growth  of  the  cholera  organ- 
isms is  characteristic.  A  small  amount  of  culture  is  then 
taken  from  Dieudonnes  plate  and  brought  in  contact  with  the 
cholera  serum,  and  the  coagulation  may  easily  be  observed 
by  the  naked  eye,  with  the  characteristic  clumping  under  the 
microscope.  For  making  examinations  of  cases  of  cholera 
which  occur  in  places  in  which  laboratory  methods  are  not 
available,  it  has  been  found  that  if  stool  specimens  taken  with 
sterile  glass  tubes  are  placed  into  agar  tubes  the  organism 
may  be  recovered  from  such  transplants  up  to  five  days  from 
the  time  that  the  specimen  was  taken.  These  tubes  are  kept 
at  ordinary  temperatures  in  the  Philippines,  which  usually 
range  from  26.7°  to  35°  C.  (80°  to  95°  F.).  These  tubes  are 
placed  into  the  agar  cultures  and  mailed  in  ordinary  mailing 
tubes. 

"Schobel^-i  in  1914,  in  Manila,  found  that  the  cholera 
organisms  live  for  six  days  in  distilled  water,  thirty-three 
days  in  ordinary  Manila  tap-water,  and  over  one  hundred  and 
six  days  in  salt  water.  Certain  food  may  be  of  great  impor- 
tance in  transmitting  the  organism,  as  in  the  case  of  milk,  in 
which  it  grows  without  producing  any  visible  alteration.  It 
has  been  shown  that  the  organism  would  live  for  at  least  two 
days  in  milk  and  forty-eight  days  in  butter.  According  to 
Koch  a  solution  of  1  to  400  of  carbolic  acid  and  1  to  25  of 
sulphate  of  copper  and  1  to  10,000  of  corrosive  sublimate  are 
sufftcient  to  arrest  development.  Ashburton-^-''  has  shown  that 
creolin,  1  to  2000,  destroys  the  vibrio.  The  cholera  organism 
has  but  feeble  resistance  to  drying  and  to  sunlight;  it  is  easily 


CHOLERA.  267 

killed  with  a  weak  germicidal  solution.  In  general,  it  may  be 
stated  that  the  organism  will  not  remain  alive  in  the  ordi- 
nary drinking-water  for  more  than  six  to  seven  days." 

Cholera  is  generally  said  to  have  an  incubation  period  of 
from  two  to  five  days,  but  in  actual  practice  it  is  found  that 
the  incubation  period  is  seldom  more  than  forty-eight  hours. 
The  cholera  conference  at  Constantinople  concluded  as  fol- 
lows :  "That  all  the  facts  cited  in  regard  to  a  period  of 
incubation  longer  than  a  few  days  are  based  upon  cases  that 
are  not  conclusive,  either  because  the  premonitory  diarrhea 
was  comprised  in  the  period  of  incubation,  or  because  the 
infection  could  have  occurred  after  the  departure  from  the 
infected  locality." 

It  quite  frequently  happens  that  the  appearance  of  the  first 
cholera  symptoms  is  preceded  by  prodromata  in  the  form  of 
diarrhea  or  a  feeling  of  malaise.  The  onset  is  usuall)^  sudden. 
The  attack  begins  with  diarrhea,  usually  attended  by  colicky 
pains  in  the  abdomen.  Vomiting  generally  occurs  later.  At 
first  food  is  vomited,  and  this  is  followed  by  watery  fluid  with 
bile  and  occasionally  blood.  The  motions  at  first  are  formed 
in  character,  but  soon  assume  the  so-called  rice-water  appear- 
ance, with  numerous  white  flakes  which,  when  examined,  are 
found  to  consist  of  mucus,  which  contains  vibrios  and  epithe- 
lial cells.-  Sometimes  blood  is  passed,  but  this  is  rare,  and 
frequently  will  be  found  to  be  due  to  hemorrhoids  or  to  some 
other  local  cause.  The  thirst  usuall}^  becomes  severe.  As  the 
purging  and  vomiting  continue,  the  urine  diminishes,  and  gen- 
erally stops  altogether.  The  blood  leaves  the  subcutaneous 
tissues,  which  causes  contractions,  the  facies  alter,  the  nose 
becomes  sharp,  the  cheek-bones  prominent,  the  eyes  sunken, 
and  the  skin  of  the  fingers  becomes  wrinkled.  Similar  wrink- 
ling takes  place  about  the  feet.  The  circulation  is  profoundlv 
affected ;  the  systolic  blood-pressure  falls,  often  to  as  low  as 
from  20  to  60.  The  pulse  becomes  quick  and  rapid,  the  heart- 
sounds  enfeebled,  the  lips  pale,  the  nails  bluish,  respiration 
rapid,  the  voice  characteristically  husky,  and  severe  cramps 
appear  in  the  muscles,  especially  in  the  arms  and  legs.  The 
mind  is  generally  clear,  but  the  patient  is  apathetic  except 
during  the  agony  produced  by  the  painful  cramps.  The  skin 
feels   cool    and    clammy,    and    the    axillary    temperature    falls 


268  TROPICAL    DISEASES. 

below  normal,  although  the  rectal  temperature  may  be  above 
normal.  The  patient  quickly  passes  into  the  second  stage  of 
the  illness  and,  unless  improvement  takes  place,  the  so-called 
algid  stage  comes  on.  The  pulse  disappears  at  the  wrist,  the 
heart-sounds  become  weak  and  irregular,  and  the  urine  com- 
pletely suppressed ;  the  diarrhea  ceases,  and  the  patient  be- 
comes comatose,  death  supervening  within  from  twelve  to 
thirty-six  hours  after  the  onset  of  the  attack.  If  the  patient 
is  to  recover  the  diarrhea  diminishes,  the  skin  becomes 
warmer,  the  pulse  and  blood-pressure  improve,  the  kidneys 
secrete,  the  subcutaneous  tissues  gradually  absorb  a  normal 
quantity  of  fluid,  and  the  appearance  of  the  subject  gradually 
returns  to  normal.  Probably  the  most  favorable  symptom  is 
the  re-establishment  of  the  renal  secretion.  Cases  sometimes 
recover  in  which  there  has  been  a  complete  suppression  of 
urine  for  more  than  seventy-two  hours.  Cholera  is  very  often 
spoken  of  as  occurring  in  three  stages.  First,  the  stage  of 
invasion,  during  which  there  is  free  evacuation ;  second,  the 
stage  of  urinary  suppression ;  third,  the  stage  of  reaction  or 
death.  In  brief,  the  prominent  symptoms  may  be  summed 
up  as  subnormal  temperature  in  the  axilla,  husky  voice,  severe 
cramps  in  the  legs  and  arms,  suppression  of  urine,  whitish 
turbid  fluid  stools,  absence  of  fluid  in  the  tissues,  and  cool, 
clammy,  profusely  perspiring  skin  and  thready  pulse.  These 
make  a  combination  so  striking  that  it  is  never  forgotten  for 
those  who  have  seen  the  disease.  The  temperature  often  falls 
to  35°  C.  (95°  F.)  in  the  mouth.  Cholera  is  frequently  spoken 
of  as  occurring  in  the  following  varieties : 

1.  Ambulant  cases,  usually  now  referred  to  as  cholera  car- 
riers, who  show  no  symptoms  of  the  disease  except  the  pres- 
ence of  the  cholera  vibrios  in  the  stools. 

2.  Choleraic  diarrhea,  characterized  by  severe  purgation 
and  the  passage  of  yellow  stools  which  contain  cholera  vibrios. 
Recovery  may  take  place  before  the  patient  passes  into  a 
typical  attack  of  the  disease. 

3.  Cholerine,  characterized  by  active  abdominal  pains, 
numerous  feculent  stools,  followed  by  rice-water  diarrhea 
lasting  for  about  a  day,  with  recovery  of  the  patient  without 
further  symptoms.  True  cholera  vibrios  are  not  found  in 
these  cases. 


CHOLERA,  269 

4.  Cholera  sicca,  a  fatal  type  of  the  disease  In  which  death 
occurs  before  the  typical  symptoms  of  diarrhea  and  vomit- 
ing- appear.  Bacteriologic  examination  of  the  stools  shows 
cholera  vibrios  almost  in  pure  culture.  In  this  type  of 
cholera  it  sometimes  happens  that  persons  are  stricken  while 
walking  on  the  street,  and,  suddenly  falling  to  the  ground,  die 
before  assistance  can  reach  them.  At  other  times  the  victim 
is  seized  during  the  night,  and  found  dead  in  bed  in  the 
morning. 

The  most  common  complication  of  cholera  is  pneumonia. 
Nephritis  is  often  given  as  a  complication,  but  this  must  be 
regarded  as  one  of  the  most  constant  lesions  of  cholera.  At 
times  gangrene  of  the  lungs  may  occur.  Abortion  in  preg- 
nant women  is  the  rule.  Secondary  affections,  however,  are 
very  common.  A  fever  resembling  typhoid  sometimes  occurs, 
but  it  is  always  of  shorter  duration  than  true  typhoid.  Vari- 
ous skin  eruptions  may  occur.  As  is  to  be  expected,  a  severe 
illness  like  that  of  cholera  is  frequently  followed  by  perma- 
nent damage  to  the  health  of  the  individual.  Extreme  anemia 
and  a  tendency  to  diarrhea  and  digestive  disturbances  may 
persist  for  a  long  time  after  convalescence  from  the  active 
choleraic  clinical  picture. 

The  diagnosis  of  cholera  during  the  presence  of  an  epi- 
demic is  very  simple,  but  the  first  few  cases  of  an  outbreak 
are  frequently  overlooked.  The  following  symptoms,  how- 
ever, should  always  lead  to  a  careful  bacteriologic  examina- 
tion of  the  stool,  in  order  to  ascertain  whether  cholera  vibrios 
are  present.  Cases  of  sudden  illness  in  which  there  is  vomit- 
ing and  purging,  subnormal  temperature,  suppression  of  urine, 
clammy  perspiration,  husky  voice,  severe  cramps  in  the  arms 
and  legs  (especially  in  the  calves),  weak  thready  pulse,  and 
wrinkling  of  the  skin  of  the  hands  and  feet  are  tentatively  to 
be  labeled  cholera. 

The  prognosis  of  cholera  is  unfavorable  in  the  general  run 
of  cases.  At  the  beginning  of  an  outbreak  the  mortalit}^  is 
often  as  high  as  90  per  cent.,  whereas  toward  the  end  of  an 
epidemic  the  death-rate  often  declines  to  about  15  per  cent. 
A  fair  average  mortality  for  a  complete  outbreak  would  be 
about  50  per  cent.  Probably  the  large  amount  of  conflicting- 
evidence  as  to  the  value  of  different  treatments  for  cholera 


270  TROPICAL   DISEASES. 

ma}^  be  explained  on  the  grounds  that  the  remedies  were 
given  at  different  periods  of  the  epidemic ;  a  treatment  that 
apparently  at  the  beginning  of  the  outbreak  was  of  no  great 
value  might,  when  used  by  another  observer  toward  the  close 
of  an  outbreak,  apparently  give  good  results, 

TREATMENT. 

The  arreat  number  of  remedies  advocated  for  cholera  are 
probably  the  best  evidence  that  no  satisfactory  treatment  has 
been  found.  On  an  experience  based  upon  many  thousands 
of  cases,  it  may  be  stated  that  the  following  probably  pro- 
duces as  satisfactory  results  as  any  other.  The  patient  is 
placed  in  a  warm  bed  with  artificial  heat,  supplied  by  hot 
blankets,  by  hot-water  bottles,  or  by  electric  pads,  the  object 
being  to  restore  the  axillary  temperature  to  normal.  A  pre- 
liminary dose  of  ^  grain  (0.03  Gm.)  of  calomel  often  seems  of 
service.  Fluid  by  mouth  is  given  freely.  Vomiting  is  a  more 
or  less  constant  symptom,  and  the  use  of  water,  which  is  of 
value  in  cleansing  the  stomach,  does  not  seem  to  increase  it. 
At  least  a  certain  amount  is  absorbed,  and  perhaps  aids  in 
the  elimination  of  toxins.  Intravenous  injection  of  normal 
salt  solution  is  employed  at  intervals  of  a  few  hours,  and  in 
quantities  designed  to  produce  a  full  pulse,  the  proper  quan- 
tity required  being  approximately  from  1  to  2  liters  (quarts). 
In  the  course  of  twenty-four  hours  a  total  volume  of  5  liters 
(quarts)  may  be  necessary.  A  stimulant  like  strychnin  in 
%0-grain  (0.001  Gm.)  doses  is  usually  necessary.  Morphin  is 
given  in  sufficient  amounts  to  make  the  patient  comfortable. 
The  treatment  advocated  by  Rogers^^  with  strong  alkaline  salt 
solution  has  not  given  any  better  results  at  the  San  Lazaro 
Hospital  in  Manila  than  ordinary  salt  solution.  In  brief,  any 
measures  which  will  induce  the  skin  to  take  over  the  work  of 
the  kidneys  should  be  employed.  In  practical  experience  it 
has  been  found  that  in  all  cases  in  which  there  is  no  marked 
suppression  of  the  urine  the  patient  will  generally  recover 
without  any  treatment  whatsoever. 

Prevention.  Two  principles  govern  the  measures  which 
should  be  taken  to  avoid  cholera.  The  first  looks  to  the 
exclusion  of  living  cholera  spirilla  from  the  gastro-intestinal 


CHOLERA.  271 

tract,  and  the  second  refers  to  preserving  any  natural  resist- 
ance, particularly  on  the  part  of  the  intestines,  to  injur}-  due 
to  the  presence  of  that  organism  in  the  intestinal  contents. 
It  is  believed  that  the  toxins  produced  by  the  cholera  spirillum 
are  not  absorbed  through  intact  intestinal  epithelium,  but 
gain  entrance  to  the  circulation  only  after  the  epithelium  has 
become  damaged,  necrosed,  or  desquamated.  Therefore  all 
dietary  indiscretions  which  might  cause  intestinal  irritation 
are  to  be  avoided.  Overfatigue  and  exposure  to  cold  are  to 
be  carefully  guarded  against,  and  it  is  advisable  not  suddenly 
to  change  the  ordinar)^  mode  of  life,  but  simply  to  follow  the 
usual  habits  in  a  temperate  manner.  The  free  use  of  alcohol 
appears  to  be  extremely  dangerous ;  those  addicted  to  its  use 
are  particularly  susceptible,  and  when  attacked  by  the  disease 
the  prognosis  is  bad. 

Care  in  the  character  of  the  food  is  important.  All  arti- 
cles which  might  carry  infection  should  be  avoided  entirely, 
or  partaken  only  after  being  cooked.  This  is  especially  the 
case  with  water  and  milk,  which  should  be  heated  to  the  boil- 
ing point.  Prolonged  boiling-  is  not  necessary,  but  to  insure 
the  death  of  the  spirillum  it  is  safest  actually  to  boil  liquid 
articles  of  food.  As  a  prophylactic  measure  it  has  been  rec- 
ommended to  take  acid  drinks,  such  as  very  weak  hydrochloric 
acid,  but  it  seems  doubtful  whether  this  is  a  wise  measure,  in 
view  of  the  danger  to  the  digestion  if  sufficient  acid  be  taken 
to  act  as  an  effective  agent  in  killing  the  spirillum.  Further- 
more, there  is  also  the  objection  that  the  use  over  a  period 
of  several  days  of  these  acidulated  solutions  produces  serious 
digestive  disturbances,  and  that  during  such  period  there  is 
interference  with  the  hydrochloric  acid  and  other  gastric 
secretions,  and,  therefore,  a  greater  susceptibility  to  cholera 
than  if  such  solutions  had  not  been  taken.  Particular  care 
should  be  exercised  ag-ainst  infection  by  those  attending  cases 
of  cholera.  They  should  disinfect  the  hands  immediately 
after  they  have  come  in  contact  with  the  dejecta  or  vomitus 
from  the  patient.  A  2  or  3  per  cent,  solution  of  carbolic  acid, 
or  1  :  1000  solution  of  bichlorid  of  mercury  may  be  used  for 
this  purpose.  Chlorid  of  lime  solutions  are  not  desirable, 
owing  to  the  fact  that  no  dependability  can  be  placed  upon 
the  amount  of  chlorin  which  they  may  contain. 


272  TROPICAL   DISEASES. 

Success  in  preventing  the  spread  of  cholera  depends  solely 
upon  the  destruction  of  the  spirilla,  and  this  means  the  safe- 
guarding- of  the  entire  human  excreta  of  any  community  in 
which  cholera  appears.  A  campaign  against  cholera  resolves 
itself  into  disinfecting  or  otherwise  safeguarding  human  ex- 
crement. In  North  American  cities  this  is  largely  safeguarded 
by  the  water  carriage  of  sewage  which  prevails  almost  every- 
where, so  that  in  such  communities  the  outbreak  of  a  large 
cholera  epidemic  is  almost  impossible.  The  next  important 
step  is  to  safeguard  the  water  supply.  Even  in  the  case  of 
water  supplies  that  are  derived  from  uninhabited  watersheds, 
it  is  believed  now  to  be  strictly  indicated  that  all  such  sup- 
plies should  be  safeguarded  by  the  introduction  of  calcium 
hypochlorite  in  quantities  which  have  been  determined  by  an 
expert  to  be  suitable  for  the  water  to  be  treated.  Cases  of 
cholera  should  be  promptly  isolated  and  placed  under  the  care 
of  competent  persons,  so  that  the  stools  and  vomitus  may  be 
promptly  disinfected,  as  well  as  all  materials  with  which  they 
may  have  come  in  contact.  For  this  purpose  5  per  cent,  car- 
bolic solution  used  in  two  or  three  times  the  bulk  of  the 
material  to  be  disinfected  perhaps  is  still  the  most  reliable  and 
efficacious  disinfectant,  although  many  of  the  coal-tar  deriva- 
tives may  be  used  if  carbolic  acid  is  not  available.  All  con- 
tacts of  cholera  cases  should  be  promptly  examined,  in  order 
to  determine  whether  they  are  cholera-vibrio  carriers,  and,  if 
so,  to  be  isolated  like  actual  cholera  cases.  Places  in  which 
cholera  cases  are  kept  should  be  strictly  safeguarded  against 
flies,  because  there  is  great  danger  of  disseminating  the  dis- 
ease from  this  source.  Another  common  means  of  spread  is 
by  the  hands  of  individuals  who  have  assisted  persons  who 
have  been  stricken  with  cholera,  and  who  do  not  realize  that 
they  may  have  become  infected.  In  more  primitive  com- 
munities it  has  frequently  been  found  possible,  after  other 
means  had  failed,  to  eradicate  cholera  by  requiring  the  entire 
community  to  immerse  its  hands  in  a  bichlorid  solution. 
Markets  where  food  articles,  like  meat,  fish  and  vegetables, 
are  sold  and  are  handled  with  the  hands,  have  often  been 
safeguarded  by  requiring  every  person  who  entered  the  mar- 
ket to  place  his  hands  in  a  barrel  of  bichlorid  solution  con- 
veniently kept  at  the  entrance  of  the  market.     In  slum  sec- 


BERIBERI.  273 

tions  in  which  cholera  appears  it  is  important  to  make  stool 
examinations  for  the  cholera  vibrio  of  all  members  of  such 
crowded  communities.  Maritime  quarantine  should  be  re- 
stricted to  the  stool  examinations  of  persons  who  have  been 
in  cholera  districts  or  who  have  come  in  contact  with  such 
persons.  It  is  no  longer  necessary  to  place  quarantine  upon 
merchandise,  because  many  practical  experiments  have  shown 
that,  even  in  articles  which  are  usually  contaminated,  it  is 
impossible  for  the  cholera  organism  to  live  for  more  than  five 
days,  except  in  a  water  supply.  The  water  supply  of  ships 
coming  from  cholera-infected  communities  should  always  be 
disinfected  with  permanganate  of  potassium.  In  communities 
where  latrines  are  commonly  used,  a  pail  system  should  be 
immediately  installed.  If  this  is  not  practicable,  the  whole 
latrine  should  be  disinfected  and  closed,  and  temporary  pits 
dug,  which  can  be  covered  over  with  lime  or  fresh  earth  im- 
mediately after  their  use.  The  dead  should  be  wrapped  in 
bichlorid  sheets  and  placed  in  hermetically  sealed  coffins  to 
guard  against  the  discharges  leaking  therefrom  before  the 
body  finally  reaches  the  grave  or  is  cremated.  In  brief,  the 
measures  to  apply  in  any  given  community  in  which  cholera 
appears  will  readily  suggest  themselves  to  any  sanitarian 
when  he  remembers  that  the  whole  question  resolves  itself 
into  the  prevention  of  human  excrement  from  cholera  cases  or 
carriers  reaching  the  mouth  of  human  beings,  and  that,  in 
order  to  be  certain  that  this  does  not  happen,  the  human 
excrement  of  the  entire  community  must  be  safeguarded  along 
the  lines  already  indicated. 

BERIBERI, 

As  synonyms  for  beriberi  the  following  are  current :  Poly- 
neuritis Endemica,  Neuritis  Multiplex  Endemica,  Hydrops 
Asthmaticus,  Synclonus  Beriberia,  Myelopathia  Tropica  Scor- 
butica, Paraplegia  Mephitica,  Serophthisis  Perniciosa  En- 
demica, Panneuritis  Endemica,  Berbiers,  Kakke  (signifying  a 
disease  of  the  legs  in  Japan  and  China),  Loempoe  (Java), 
Kaki-lem-but,  Hinchazon  de  los  Negros  y  Chinos,  Maladie  des 
Sucreries  (French  Antilles),  Hinchazon  (Cuba),  Inchacao,  or 
Pernerias  (Brazil). 

18 


274 


TROPICAL   DISEASES. 


Beriberi  is  a  serious  disease,  the  effects  of  which  manliest 
themselves  principally  by  degenerative  changes  in  the  nerves, 
by  heart  attacks,  by  dropsy,  and  frequently  by  making  a 
cripple  of  the  person  attacked. 

As  beriberi  is  intimately  connected  with  the  effects  of 
nutritional  disturbances,  it  is  more  than  likely  that  the  disease 
has  been  present  from  the  very  earliest  times.  According  to 
Scheube,-^'^  beriberi  is  mentioned  by  Strabo  and  Dion  Cassius 
as  having  attacked  the  Roman  army  while  in  Arabia  in  24  b.  c. 
Kakke  is  frequently  mentioned  in  early  Chinese  writings,  and 
it  is  minutely  described  in  a  pamphlet  of  the  seventh  century. 


Fig.  9. — A  healthy  chicken,  used  in  beriberi  research. 


It  is  also  recorded  as  having  occurred  in  Japan  in  the  ninth 
century.  Bontius  of  Europe  described  the  disease  under  the 
term  beriberi  in  1758.  Tulpius,  a  Dutch  physician,  described 
the  disease  in  a  person  who  had  returned  to  Holland  from  the 
East  Indies  prior  to  1800.  Since  then  the  literature  of  the 
disease  has  steadily  grown.  There  is  much  reason  to  believe, 
however,  that  a  number  of  other  diseases  have  been  confused 
with  beriberi.  It  is  quite  probable  that  uncinariasis  has  been 
frequently  mistaken  for  it.  There  is  much  reason  to  believe, 
however,  that  the  incidence  of  the  disease  in  the  Orient  has 
markedly  increased  since  the  advent  of  steam  rice-mills.  The 
old  hand  process  of  husking  and  cleaning  the  rice  did  not,  as 
a  rule,  remove  the  cortical  layer  of  the  grain. 

There  have  been  notably  large  numbers  of  deaths  due  to 
beriberi  in  public  institutions,  in  the  Japanese  Navy,  on  ships, 


BERIBERI. 


275 


jails,  insane  hospitals,  and  other  places  where  polished  rice 
has  been  the  staple  article  of  diet.  In  1904  and  1905  it  is 
stated  that  24  per  cent,  of  the  entire  sick  and  wounded  in  the 
Japanese  armies  were  disabled  by  it.  It  is  estimated  that 
there  are  annually  at  least  a  hundred  thousand  deaths  and  a 
half-million  cases  of  illness  due  to  beriberi  throughout  the 
Orient.  There  is  much  reason  to  believe  that  the  disease  in 
some  countries  is  indirectly  associated  with  infant  mortality 
and  morbidity.  In  Manila,  for  instance,  where  over  one-half 
of  the  children  die  before  they  reach  their  first  birthday,  the 
mortality   is   much   greater   among  breast-fed    children   than 


Fig.  10 — Same  chicken.    Paralysis  after  being  fed  exclusively  on 
white  rice  for  four  weeks. 

among  bottle-fed  children.  The  health  of  breast-fed  infants 
of  mothers  who  subsist  on  polished  rice  as  a  staple  article  of 
diet  improves  in  a  remarkable  manner  when  the  extract  of 
lice  polishings  is  fed  to  such  infants. 

Beriberi  prevails  extensively  in  Japan,  China,  Philippine 
Islands,  Borneo,  Indo-China,  Straits  Settlements,  Federated 
Malay  States,  Java,  and  Sumatra  in  the  Eastern  Hemisphere, 
and  in  other  places  where  people  whose  staple  article  of  diet 
is  polished  rice  have  migrated.  It  is  particularly  common  on 
vessels  which  have  Asiatic  crews.  In  the  Western  Hemi- 
sphere the  disease  has  been  frequently  reported  in  Brazil,  also 
among  the  natives  of  Iceland,  and  in  these  countries  is  due 
to  an  unbalanced  ration. 

That  beriberi  is  intimately  associated  with  diet  cannot 
longer  be   successfully   disputed,   although   there   are   still   a 


276  TROPICAL   DISEASES. 

number  of  observers  in  various  parts  of  the  world  who  cling 
tenaciously  to  the  infection  theory,  or  maintain  that  the  cause 
of  the  disease  has  not  yet  been  adequately  demonstrated. 
Without  concerning  ourselves  at  great  length  with  the  vari- 
ous theories  which  have  been  advocated,  it  may  be  said  with- 
out successful  contradiction  that  beriberi  can  be  completely 
eradicated  among  a  people  whenever  a  properly  balanced  diet 
is  used  by  them.  The  practical  evidence  in  support  of  this 
contention  is  overwhelming.  In  the  Philippine  Islands,  for 
instance,  where  more  than  a  thousand  deaths  occurred  annu- 
ally in  public  institutions,  as  in  the  leper  colony,  insane  hos- 
pitals, prisons  and  orphan  asylums,  the  disease  immediately 
disappeared  when  an  unpolished  rice  diet  was  substituted  for 
the  polished  rice,  and  reappeared  when  polished  rice  was 
again  used.  Convincing  proof  that  polished  rice  was  an 
insufficient  diet  became  unexpectedly  available  in  the  Culion 
Leper  Colony  when  the  disease  reappeared  in  1912.  An 
investigation  showed  that  during  the  autumn  of  1911  it 
became  impracticable  for  the  Philippine  Government  to  ob- 
tain an  adequate  supply  of  unpolished  rice,  and  in  November, 
1911,  the  use  of  polished  rice  was  begun  at  Culion  and  con- 
tinued until  February,  when  unpolished  rice  was  substituted 
and  has  been  used  ever  since.  In  January,  1912,  there  were 
2  deaths  from  beriberi;  in  February,  36;  in  March,  30;  in 
April,  3 ;  and  since  that  time  there  has  been  no  further  record 
of  deaths  from  beriberi  in  Culion,  or  in  any  other  Philippine 
Civil  Government  institutions.  This  experience  shows  that 
in  a  population  involving  approximately  three  thousand  peo- 
ple, among  whom  beriberi  was  continuously  present  for  more 
than  three  years,  the  disease  disappeared  when  unpolished 
rice  was  used,  reappeared  when  polished  rice  was  substituted, 
and  disappeared  again  when  unpolished  rice  was  used.  Sim- 
ilar experiments  have  been  reported  by  Fraser  and  Stanton^^ 
in  the  Federated  Malay  States;  by  Highet^^  in  Siam ;  by 
Schiiffner^o  j^  Sumatra;  Eijkmann^i  in  Java,  and  Shiga'*^  in 
Japan.  Acting  on  this  knowledge  the  principal  civil  medical 
officers— Ellis  in  the  Straits  Settlements,  Sansom  in  the  Fed- 
erated Malay  States,  Cobb  in  Borneo,  and  Highet  in  Siam — 
have  been  encouraging  the  use  of  unpolished  rice  in  civil  insti- 
tutions, and  the  number  of  cases  of  beriberi  have  fallen  in 


BERIBERI.  277 

direct  proportion  to  the  completeness  with  which  the  unpol- 
ished rice  was  substituted  for  the  polished  rice. 

There  has  been  considerable  difference  of  opinion  as  to 
what  constitutes  the  essential  lesion  of  beriberi.  It  has  fre- 
quently been  referred  to  as  a  disease  of.  the  blood,  by  others 
as  a  disease  of  the  arteries.  Since  the  extensive  work  of 
Scheube  and  of  Baelz,43  beriberi  has  been  considered  to  be  a 
peripheral  neuritis.  There  is,  however,  much  evidence  to 
show  that  the  disease  is  of  central  origin,  and  that  the  spinal 
cord  and  brain  are  involved.  As  beriberi  is  a  nutritional  dis- 
ease, and  as  the  symptoms  are  due  to  faulty  metabolism,  it 
seems  logical  to  assume  that  before  the  peripheral  nerves  are 
attacked  there  must  be  disturbance  of  the  central  nervous 
system. 

On  inspection  in  cases  of  so-called  wet  beriberi,  the  whole 
body  is  swollen,  especially  the  lower  extremities.  On  open- 
ing the  abdomen  large  quantities  of  fluid  are  found.  There 
is  also  an  excess  of  pericardial  fluid.  There  is  nothing  spe- 
cially characteristic  about  any  of  the  abdominal  organs  that 
would  not  be  found  in  cases  of  dropsy  due  to  other  causes. 
The  heart  is  generally  hypertrophied.  There  is  serous  effu- 
sion into  the  pericardium,  pleural  cavities,  peritoneum  and 
cellular  tissue.  This  tendency  to  effusion  with  cardiac  dilata- 
tion aids  to  distinguish  beriberi  from  other  forms  of  multiple 
neuritis.  A  lesion  of  the  duodenum  which  is  referred  to  as  a 
duodenitis  is  reported  to  be  present  by  many  authors,  but  it 
is  not  a  characteristic  lesion,  and  its  presence  is  actually  dis- 
puted by  other  authors.  Microscopically,  the  infected  nerves 
on  section  show  the  characteristic  lesion  of  nerve  degenera- 
tion. 

The  vagi  probably  show  the  most  constant  nerve  lesions, 
and  there  are  changes  in  the  vagal  nucleus  and  the  vagal 
ganglia.  The  peripheral  nerves  of  the  limbs  are  next  most 
frequently  affected. 

In  dry  beriberi,  with  the  exception  of  the  lack  of  effusion, 
the  post-mortem  findings  are  almost  identical  with  those  of 
wet  beriberi. 

In  acute  cases  the  right  heart  is  always  dilated,  and  is 
hypertrophied  in  older  cases.  The  left  ventricle  may  be  mod- 
erately dilated,  but  it  is  rare  to  find  it  hypertrophied.  ■  The 


278  TROPICAL   DISEASES. 

myocardium  generally  shows  fatty  degeneration  and  round- 
cell  infiltration  under  the  endo-  and  epi-  cardium.  These 
heart  changes,  according  to  Scheube,'*'*  are  the  same  as  found 
in  rabbits  when  both  vagi  are  cut. 

The  muscles  contain  many  atrophied  fibers  among  the 
normal.  The  diseased  fibers  first  lose  their  striation.  Colloid 
degeneration  takes  place,  with  proliferation  of  the  nuclei  of 
the  sarcolemma.  As  the  atrophy  proceeds,  the  connective 
tissue  increases. 

It  is  usually  stated  that  the  incubation  period  of  beriberi 
is  unknown.  Judging  from  an  experience  based  on  ob- 
servation of  several  thousand  persons,  it  is  probable  that 
the  incubation  period,  where  polished  rice  and  fish  are 
the  staple  articles  of  diet,  is  about  sixty  days.  Beriberi  may 
be  described  as  occurring  in  three  forms.  First,  dropsical  beri- 
beri; second,  dry  beriberi;  third,  low-grade  beriberi.  The  dis- 
ease may  be  acute  in  onset.  Although  the  great  majority  of 
cases  begin  very  insidiously,  the  patient  usually  loses  appetite, 
often  has  pain  in  the  abdomen,  and  frequently  complains  of 
nausea.  Incipient  beriberi  can  often  be  detected  by  the  pain 
provoked  by  making  pressure  over  the  epigastrium.  The  tem- 
perature is  usually  normal.  Probably  one  of  the  first  definite 
clinical  symptoms  of  the  disease  is  associated  with  the  heart, 
manifesting  itself  by  a  sensation  of  oppression  over  the  peri- 
cardium. There  is  visible  throbbing  of  the  vessels  of  the  neck, 
epigastric  pulsation,  cardiac  palpitation,  dyspnea,  and  marked 
acceleration  of  the  heart  upon  the  slightest  exertion.  The 
right  side  of  the  heart  is  dilated,  and  a  hemic  murmur  may  be 
heard.  There  is  a  decrease  in  urine  which  is  attributed  to  the 
cardiac  insufficiency,  and  in  the  wet  form  dropsy  appears. 
This  may  be  confined  to  slight  edema  over  the  tibia,  or  may 
be  very  extensive  and  consist  of  effusions  into  the  peritoneal, 
pericardial  and  pleural  cavities. 

In  the  beginning  of  the  attack  there  are  exaggerated  knee- 
jerks  and  a  sense  of  heaviness  and  lack  of  control  in  the  legs. 
Gradually  the  knee-jerks  diminish,  and  finally  disappear  alto- 
gether. The  patient  may  become  incapable  of  walking,  but 
before  reaching  this  stage  acquires  a  very  peculiar  gait,  which 
somewhat  resembles  that  of  locomotor  ataxia.  He  usually 
walks  with  the  legs  wide  apart,  cannot  stand  with  closed  eyes. 


BERIBERI.  279 

and  has  a  sensation  of  walking  on  something  soft.  The  calves 
become  tender,  and  various  forms  of  hyperesthesia  appear, 
especially  about  the  legs  and  arms.  The  anterior  tibial  and 
peroneal  muscles  seem  to  be  more  tender  and  waste  faster 
than  other  muscles.  The  forearms  may  be  paralyzed,  with 
wrist-drop  and  loss  of  power  in  the  grip.  The  muscles  grad- 
ually waste,  and  electrical  reactions  of  degeneration  set  in.  In 
the  early  stage  of  the  disease  a  very  rough  physical  test  for 
beriberi  is  the  inability  of  patients  to  jump  on  a  box  12  inches 
(30.4  cm.)  high.  The  paralysis  spreads  to  the  muscles  of  the 
calf,  thigh,  gluteal  region,  arm,  hand,  and,  in  severe  cases,  to 
the  muscles  of  respiration,  and,  in  rare  instances,  to  the  ocular 
muscles.  Various  paresthesias  occur.  The  patient  often  has 
the  sensation  of  touching  things  with  gloves  on.  The  sensa- 
tions of  heat,  cold  and  pain  are  often  lost.  This  usually  begins 
in  the  feet  and  spreads  upward.  The  numbness  of  the  fingers 
prevents  the  patient  from  performing  many  simple  acts,  as,  for 
instance,  buttoning  the  collar,  sewing,  and  working  with  tools. 
The  innervation  of  the  heart  is  much  affected,  and  gives  rise 
to  many  indefinite  murmurs.  Palpitation  and  epigastric  pul- 
sation are  very  common.  The  pulse  is  usually  increased  in 
frequency,  and  is  of  low  tension.  Death  usually  results  from 
cardiac  failure.  The  blood  does  not  show  much  abnormality, 
although  there  may  be  some  evidences  of  anemia.  The  urine 
is  usually  diminished  when  there  is  edema,  but  the  volume 
greatly  increases  when  the  patient  begins  to  improve. 

There  is  no  great  clinical  diflrerence  between  the  wet  and 
dry  forms.  On  inspection,  however,  the  distinction  between 
the  two  forms  of  the  disease  is  most  striking.  One  has  the 
typical  appearance  of  dropsy,  and  the  other  shows  great 
emaciation.  According  to  some  authors,  the  wet  and  dry 
forms  of  the  disease  are  only  the  early  and  late  stages  of 
beriberi.  This,  however,  is  disputed.  Some  authors  state 
that  the  difference  in  the  two  forms  of  the  disease  is  actually 
due  to  differences  in  the  action  caused  by  substances  or  the 
absence  of  substances  in  the  food.  The  digestion  is  usually 
fair,  the  tongue  clean.  Vomiting  is  regarded  as  an  unfavor- 
able symptom.  Constipation  is  frequent,  and  the  temperature 
may  be  normal,  or  even  subnormal.  The  quantity  of  urine 
depends  largely  on  the  st^ge  of  the  disease;  when  ^ropsy  i§ 


280  TROPICAL   DISEASES. 

passing  off  there  is  an  increase  in  the  amount  of  urine.  Some- 
times the  larynx  is  partly  or  completely  paralyzed,  and  the 
voice  is  raucous,  or  even  completely  lost.  Death  may  occur 
during  any  stage  of  the  disease,  and  frequently  follows  any 
unusual  strain  that  may  be  put  upon  the  heart,  as,  for  in- 
stance, attempting  to  rise  in  bed,  or  walk  or  climb.  In  the 
great  majority  of  instances  the  disease  becomes  chronic  if  not 
placed  under  treatment.  In  some  Eastern  countries  special 
hospitals  have  been  provided  to  care  for  beriberi  paralytics. 
If  treatment  and  proper  diet  are  provided,  even  after  the 
paralysis  has  extended  over  a  period  of  some  months,  recov- 
ery usually  takes  place,  but  it  is  very  slow.  There  is  appar- 
ently no  immunity  conferred  by  one  attack  of  the  disease.  In 
addition  to  those  actually  ill  with  the  disease,  there  are  many 
others  who  have  only  slight  symptoms,  which  are  not  suffi- 
cient to  prevent  them  from  pursuing,  in  a  handicapped  way, 
their  usual  avocations. 

Beriberi  patients  are  especially  likely  to  contract  malaria, 
dysentery  and  tuberculosis. 

The  sequelae  of  beriberi  depend  very  largely  upon  the 
stage  of  the  disease  at  which  effective  treatment  is  adminis- 
tered. If  the  degeneration  of  the  nerves  has  lasted  over  a 
period  of  years,  many  sufferers  of  beriberi  become  perma- 
nently paralyzed,  especially  in  the  lower  extremities,  and  are 
unable  to  walk. 

The  diagnosis  may  be  based  upon  the  loss  of  knee-jerks, 
tenderness  on  pressure  over  the  epigastric  region,  patches  of 
hyperesthesia,  and,  later,  anesthesia  of  the  legs,  pain  on  press- 
ing the  muscles  of  the  calf,  and  of  the  arms,  pretibial  edema, 
absence  of  albuminuria  and  absence  of  fever.  Numerous 
cases  are  met  with  among  persons  who  have  been  living  on 
a  one-sided,  unbalanced,  monotonous  ration.  Confusion  is 
prone  to  occur  in  differentiating  beriberi  from  arsenic,  lead 
and  other  poisons,  and  in  such  instances  the  differentiation  is 
sometimes  difficult,  and  generally  depends  upon  the  dietary 
history  and  the  occupation  of  the  patient.  Argyll  Robertson 
pupil  helps  to  separate  it  from  locomotor  ataxia,  and  also  the 
Wassermann  and  luetin  tests.  Uncinariasis  is  frequently 
confused  with  beriberi,  but  in  this  quandary  the  anemia  and 
the  presence  of  the  parasites  make  a  sharp  distinction. 


BERIBERI.  281 

The  mortality  of  the  drsease  varies  very  greatly,  and  prob- 
ably depends  upon  the  stage  of  the  disease  during  which  the 
patient  comes  u'nder  treatment.  The  mortality  has  been  given 
at  from  2  to  60  per  cent.  In  the  pernicious  forms  the  disease 
is  nearly  always  fatal.  The  avoidance  of  cardiac  strain  is  an 
important  point  in  a  favorable  prognosis. 

TREATMENT. 

Treatment  should  consist  of  rest  in  bed  and  extreme  pre- 
caution to  prevent  cardiac  strains.  In  recent  years  the  admin- 
istration of  an  extract  made  from  the  polishings  of  rice  has 
been  used  with  apparent  success.  Guerrero^*^  h^s  reported  a 
series  of  447  cases  treated  with  the  rice  extract  with  a  mor- 
tality of  5.59,  whereas  the  control  series  of  349  in  which  the 
rice  extract  was  not  used  showed  the  mortality  of  7.16.  This 
extract,  according  to  Vedder,"'^  is  made  as  follows : 

"Rice  polishings,  or  tiqui-tiqui,  may  be  obtained  from  any 
rice-mill,  but  should  perferably  be  from  a  recent  milling. 
The  finest  grade  of  polishings  should  be  carefully  selected, 
since  some  of  this  product  is  very  coarse  and  consists  mostly 
of  hulls.  The  tiqui-tiqui  is  first  sifted  to  remove  hulls  and 
weevils.  Gauze  of  about  seven  meshes  to  the  centimeter  is 
used  for  this  purpose.  This  fine  powder  is  weighed  and 
mixed  with  90  per  cent,  alcohol  in  the  proportion  of  3  liters 
(quarts)  of  alcohol  to  each  kilo  of  polishings.  It  is  then 
allowed  to  macerate  for  twenty-four  hours.  A  glass  jar  or 
white  enameled  receptacle  serves  for  this  purpose,  and  the 
mixture  should  be  repeatedly  stirred  or  shaken,  since  the 
tiqui-tiqui  sinks  rapidly  to  the  bottom,  forming  a  densely 
packed  mass  which  the  alcohol  penetrates  with  difficulty. 
During  the  extraction  the  alcohol  becomes  of  a  deep-green 
color,  due  to  the  fat  that  has  been  dissolved  out.  At  the  end 
of  twenty-four  hours  the  alcohol  is  siphoned  ofif  and  filtered 
until  absolutely  clear.  Since  a  very  considerable  quantity 
remains  in  the  tiqui-tiqui,  this  should  be  squeezed  in  a  press 
or  washed  with  fresh  alcohol,  and  the  residuum  filtered  and 
added  to  the  alcoholic  filtrate  already  obtained.  The  extrac- 
tion should  then  be  repeated  several  times,  again  using  3  liters 
(quarts)  of  alcohol  to  each  kilo  of  polishings.    This  is  neces- 


282  TROPICAL   DISEASES. 

sary  because  neuritis-preventing  substances  are  only  slightly 
soluble  in  cold  90  per  cent,  alcohol,  and  experience  has  shown 
that  if  the  polishings  are  not  repeatedly  extracted  the  full 
therapeutic  action  of  the  polishings  is  not  obtained.  The 
combined  alcoholic  iiltrate  is  then  placed  in  a  water  bath  pro- 
vided with  a  thermometer,  and  an  electric  fan  is  arranged  so 
as  to  throw  a  strong  current  of  air  on  the  surface  of  the 
alcohol.  As  a  result  of  the  heat  and  the  movement  of  air 
the  alcohol  repeatedly  evaporates.  It  is  essential  that  the 
temperature  of  the  extract  should  not  be  permitted  to  rise 
above  80°  C.  (176°  F.),  since  extended  observation  has  shown 
that  greater  heat  is  liable  to  decompose  the  active  neuritis-pre- 
venting principle.  Whenever  the  temperature  of  the  extract 
approaches  80°  C.  (176°  F.)  the  fire  should  be  extinguished 
until  the  temperature  drops.  This  process  is  continued  until 
all  the  alcohol  is  evaporated.  The  residue  is  poured  into  a 
separating  funnel  and  allowed  to  stand  for  about  an  hour, 
when  it  will  be  observed  that  the  liquid  has  separated  into 
two  layers.  The  upper  and  larger  portion  is  of  a  deep-green 
color  and  consists  of  the  fat.  The  lower  and  smaller  la5^er  is 
brown  in  color,  of  syrupy  consistency,  and  contains  a  number 
of  substances  that  have  been  extracted  by  the  alcohol.  This 
lower  layer  is  carefully  drawn  ofif,  leaving  the  fat  behind.  It 
varies  in  amount,  but  about  25  mils  (6.7  fo)  usually  will  be 
obtained  from  each  kilo  of  polishings.  The  brown  syrupy 
fluid  so  obtained  from  1  kilo  of  polishings  is  diluted  to  60  mils 
(2  f,))  with  distilled  water,  whereupon  a  heavy  precipitate  is 
formed.  This  precipitate  consists  of  substances  that  were 
soluble  in  alcohol,  but  are  insoluble  in  water.  After  allowing 
the  mixture  to  stand  for  a  while  the  precipitate  settles  and  the 
clear  fluid  is  filtered  off.  This  filtrate  constitutes  the  extract 
as  we  have  used  it.  Each  60  mils  (2  f^)  contains  the  sub- 
stances that  have  been  extracted  by  this  method  from  1  kilo 
of  polishings." 

Guerrero^''"  recommends  that  15  mils  (j/z  fo)  of  an  extract 
composed  of  1  part  to  15  should  be  administered  to  a  child 
in  the  course  of  twenty-four  hours,  and  proportionate  doses 
for  an  adult.  He  recommends  in  acute  cases  that  5  mils  (1.35 
f3)  of  extract  should  be  administered  every  half-hour  until 
the  acute   symptoms   subside.     The  diet  is   of  the   greatest 


BERIBERI.  283 

importance  in  the  treatment  of  the  disease.  In  the  Eastern 
countries  it  has  been  found  of  great  value  to  use  a  bean 
known  as  the  Phaseolus  radix  (often  called  Mongo  in  the 
Philippines)  in  such  quantity  as  the  patient  can  readily 
digest.  The  use  of  ordinary  yeast  in  teaspoonful  doses  at 
intervals  of  every  three  or  four  hours  is  reported  to  be  of 
value.  Beans,  peas,  meat  and  whole  bread  are  also  indicated. 
Tonics  such  as  iron,  quinin  and  strychnin  should  also  be 
used.  As  soon  as  the  acute  heart  symptoms  subside  in  cases 
which  suffer  from  paralysis  of  the  limbs,  a  certain  amount  of 
exercise  should  be  insisted  upon.  In  some  hospitals  this  is 
accomplished  by  stretching  a  rope  at  the  height  of  about  5 
feet  along  a  veranda  or  ward,  and  having  patients  walk  up 
and  down  and  steady  themselves  with  the  rope.  Electricity 
and  massage  are  also  valuable  adjuvants.  If  rice-extract  in 
acute  cases  is  given  promptly,  it  will  not  often  be  necessary 
to  make  use  of  strychnin ;  however,  if  the  extract  is  not 
available,  active  stimulation  should  be  employed  in  the  same 
manner  as  in  other  cases  of  cardiac  failure.  Rice  should  be 
eliminated  from  the  diet. 

Various  measures  have  been  suggested  for  making  effec- 
tive the  knowledge  as  to  the  manner  in  which  beriberi  may 
be  prevented.  A  campaign  of  education  has  been  most  per- 
sistently carried  out  in  the  Philippine  Islands  during  the  past 
four  years,  principally  through  teaching  some  400,000  pupils 
in  the  public  schools.  Unfortunately,  even  after  the  public 
was  prepared  to  use  the  unpolished  rice,  it  has  been  impos- 
sible to  obtain  it,  because  the  rice-mill  managers  did  not  care 
to  change  their  process  of  manufacture.  Also,  it  so  happens 
that  the  rice-exporting  countries  are  not  always  the  ones 
whose  inhabitants  subsist  on  rice  and  fish,  and  as  their  own 
population  is  often  not  affected,  they  do  not  take  au}^  great 
interest  in  preventing  the  disease  in  other  countries.  The 
Far  Eastern  Association  of  Tropical  Medicine,  at  its  meeting 
held  in  Manila  in  1910,  passed  a  resolution  calling  the  atten- 
tion of  all  governments  concerned  to  the  desirabilij:y  of  bring- 
ing about  the  use  of  unpolished  rice.  This  resolution  was 
again  reaffirmed  at  the  meeting  held  in  Hong  Kong  in  Janu- 
ary, 1912.  The  International  Congress  of  Medicine  and 
Surgery  held  in  London  during  August,  1913,  substantially 


284  TROPICAL   DISEASES. 

reiterated  the  resolutions  of  the  Far  Eastern  Association  of 
Tropical  Medicine  referred  to  above.  The  knowledge  of  the 
prevention  of  beriberi  has  now  been  available  for  over  five 
3-ears,  and  so  far  there  has  been  practically  no  application  of 
this  knowledge  outside  of  government  institutions.  To  sum 
up,  education  has  been  faithfully  tried  in  one  countr}^,  and  has 
made  very  little  progress.  Inducing  persons  to  add  other 
constituents  to  their  ration,  which  would  give  them  the  sub- 
stance that  is  missing  from  polished  rice,  has  been  tried  in 
Hong  Kong,  and  has  only  succeeded  in  the  case  of  persons 
in  hospitals  or  jails.  In  Sumatra,  notwithstanding  the  efforts 
of  the  medical  profession,  little  progress  has  been  made.  In 
view  of  these  failures  the  following  is  suggested : 

Place  a  tax  of,  say,  2  cents  United  States  currency  (1 
penny)  per  pound  on  polished  rice.  United  action  by  the 
British  Colonies  would,  in  all  probability,  result  in  other 
countries  interested  adopting  similar  standards.  Rice-mill 
owners  would  immediately  find  it  desirable  to  make  unpol- 
ished rice,  and  the  use  of  polished  rice  as  a  staple  article  of 
diet  would  soon  cease.  There  would  be  no  additional  burden 
placed  upon  the  ordinary  consumer,  and  the  fiscal  arrange- 
ments in  all  countries  concerned  with  regard  to  rice  would 
remain  in  statu  quo.  At  the  same  time,  it  would  not  deprive 
those  who  use  European  diet  from  obtaining  at  a  small 
increased  cost  the  polished  rice  which  they  prefer,  and  which, 
owing  to  their  varied  diet,  does  them  no  harm. 

The  classification  of  rice  into  polished  and  unpolished  rice 
can  be  based  upon  a  simple  chemical  test.  Phosphorus  pen- 
toxid  (P2O5)  is  a  safe  indicator  as  to  the  degree  of  polishing 
and  as  to  whether  a  rice  contains  a  sufficient  amount  of  the 
beriberi-preventing  principle.  It  has  been  ascertained  by 
experiments  that  rice  which  contains  0.4  per  cent,  or  more  of 
phosphorus  pentoxid  will  not  cause  beriberi,  and,  therefore, 
may  be  called  unpolished  rice,  whereas  rice  containing  a 
lesser  amount  of  phosphorus  pentoxid  may  cause  beriberi 
and  be  classed  as  polished  rice. 

It  is  quite  possible  that  there  may  be  serious  objections 
on  the  part  of  the  people  directly  affected  by  having  their 
white,  polished  rice  changed  to  a  darker,  unpolished  variety. 
This  difficulty  could  probably  be  overcome  by  education  and 


BERIBERI.  285 

by  inducing  the  millers  to  produce  a  clean,  partly  polished 
rice  which  would  be  acceptable  to  the  people,  and  yet  not 
cause  beriberi. 

Low-grade  Beriberi.  In  this  form  of  the  disease  the 
symptoms  are  but  slight.  The  ration  is  probably  only  slightly 
deficient.  Its  presence  may  go  unsuspected  for  a  long  time. 
The  patient  has  a  number  of  indefinite  symptoms.  Often 
there  is  slight  pain  in  the  abdomen,  especially  on  pressure. 
There  may  be  pain  in  the  calves  of  the  legs.  Palpitation  of 
the  heart  on  slight  exertion  is  common.  At  times  the  pres- 
ence of  beriberi  is  discovered  in  mothers  of  nursing  infants 
when  the  health  of  the  mother,  and  especially  that  of  the 
child,  improves  upon  administering  the  extract  of  rice  polish- 
ings  to  the  mother. 

Infantile  Beriberi.  In  the  Philippines  infantile  beriberi  is 
known  also  by  the  terms  Taon  and  Taol  Suba.  For  some 
time  it  has  been  suspected  a  large  percentage  of  the  abnormal 
infant  mortality,  especially  in  the  Philippines,  is  closely  asso- 
ciated with  beriberi  in  the  mother.  It  manifests  itself  prob- 
ably in  the  form  of  infantile  beriberi,  or  other  condition  that 
may  be  ascribed  to  faulty  nutrition  among  breast-fed  infants. 
This  seems  all  the  more  probable  when  it  is  remembered  that 
the  mortality  among  breast-fed  infants  in  the  Philippines  is 
about  double  that  of  bottle-fed  children.  In  Europe  avid  in 
America  the  reverse  is  true,  viz. :  the  mortality  is  always 
lower  among  breast-fed  infants.  Special  investigations  of 
this  question  have  been  made  by  McLaughlin,  Andrews, 
Vedder,  Guerrero,  Albert  and  others,  but  the  number  of  cases 
studied  and  the  amount  of  data  presented  have  not  been 
regarded  as  sufficient  to  draw  definite  conclusions.  As  over 
half  of  the  infants  born  in  Manila  die  before  they  reach  1  year 
of  age,  it  will  be  apparent  that  this  is  a  matter  which  afifects 
many  thousands  of  lives,  and  additional  information  is  most 
desirable  before  recording  definite  conclusions. 

A  striking  example  of  this  form  of  the  disease  is  seen  in 
the  mothers  of  nursing  infants  who  use  an  unbalanced  diet. 
Children  who  are  cross,  cry,  fail  to  sleep  and  are  emaciated 
often  improve  in  a  miraculous  manner  when  an  extract  of  the 
cortical  layer  of  the  rice  is  administered  to  the  children  or  even 
to  the  mother  who  feeds  them  by  the  breast. 


286  TROPICAL   DISEASES. 

TRYPANOSOMIASIS. 

Sleeping-  Dropsy,  Trypanosome  Fever,  Negro  Lethargy 
and  "Morbus  Dormitious  are  common  synonyms  for  the  vari- 
ous types  of  acute  and  chronic  infections  due  to  trypanosomes 
described  by  Button,  Stephens  and  Fanthan. 

The  Trypanosoma  gamhiense  of  Dutton'^^  jg  chiefly  spread 
by  the  Glossina  palpalis.  The  Trypanosoma  rhodesiense  of 
Stephens  and  Fanthan'*^  is  spread  by  the  Glossina  morsitans. 
The  trypanosomiases  are  characterized  by  an  inflammatory 
condition  of  the  lymphatic  system  leading  to  encephalitis. 

Mention  is  made  of  "Sleeping  Sickness"  in  the  book  en- 
titled "Navy  Surgeon,"  by  John  Atkins,  published  in  1734. 
He  describes  a  sleeping  "distemper"  which  he  found  among 
the  natives  of  the  Guinea  Coast  in  1721.  Since  that  time  the 
disease  has  been  frequently  mentioned  in  the  literature.  It 
was  not,  however,  until  1901  that  Ford  and  Dutton^o  found  a 
trypanosome  in  the  blood  of  a  patient  suffering  from  a 
peculiar  type  of  fever.  In  1901  Castellani,-'^!  j^  Uganda, 
found  a  trypanosome  in  the  spinal  fluid  of  a  person  suffering 
from  sleeping  sickness.  Later  Law  and  Castellani'^2  called 
attention  to  the  two  constant  symptoms,  namely,  fever  and 
the  peculiar  tremors.  In  1903  Sir  David  Bruce  and  Navarro^'^ 
showed  that  the  disease  was  spread  by  a  Glossina  palpalis. 
Kleine,-'^'*  in  a  series  of  important  researches,  showed  that  the 
micro-organism  undergoes  a  cycle  of  development  in  the  fly,  which 
was  confirmed  by  Sir  David  and  Lady  Bruce. ^^  In  1907  a 
bureau  under  the  British  Colonial  Office  for  the  study  of  the 
disease  was  founded.  In  1910  Stephens  and  Fanthan-"*® 
created  a  new  species. 

The  disease  is  almost  chiefly  confined  to  the  West  Coast 
of  Africa  and  Sierra  Leone.  Trypanosomes  have  been  fre- 
quently carried  to  other  tropical  regions,  but  probably  owing 
to  the  absence  of  the  special  fly  necessary  to  its  development 
the  disease  has  not  spread.  Cases  are  frequently  introduced 
into  England  and  the  United  States,  but  no  dissemination  has 
been  noted  as  a  result  of  this  experience.  Trypanosomiases 
are  probably  due  to  several  species  of  trypanosomes,  but  the 
Trypanosoma  gamhiense  and  the  Trypanosoma  rhodesiense 
cause   the   more   common    types   of   the   disease.      In    South 


TRYPANOSOMIASIS.  287 

America,  specially  in  the  State  of  Minas  in  Brazil,  a  try- 
panosome  fever  occurs  which  is  due  to  the  Trypanosoma  cruzi 
Chagas,  which  is  spread  by  the  bug  Lamus  megistus  (Bur- 
meister).  The  symptoms  of  the  disease  are  entirely  distinct 
from  African  trypanosomiasis.  One  type  resembles  myx- 
edema, another  pseudomyxedema.  Many  cases  have  hyper- 
trophy of  the  lateral  lobes  of  the  thyroid  gland.  It  is  fre- 
quently confounded  with  severe  cases  of  uncinariasis.  The 
disease  is  very  rare,  and  scarcely  warrants  a  full  description 
in  a  book  of  this  kind. 

The  pathology  of  the  several  trypanosomiases  appears  to 
be  restricted  to  a  chronic  inflammation  of  the  lymphatic  sys- 
tem, which  may  be  due  to  the  toxin  elaborated  by  the  organ- 
ism. The  trypanosome  either  enters  the  lymph-stream  of  the 
human  host  after  the  bite  of  the  fly,  or  it  is  blocked  in  the 
lymphatic  gland  into  which  it  passes.  It  is  thought  that  per- 
haps the  organism  may  find  its  way  into  the  blood-stream, 
and  then  by  rupture  of  a  capilla.ry  it  may  reach  the  lymph- 
channels. 

Prevention  measures  must  be  based  upon  the  destruction 
of  the  Glossina  palpalis  and  the  Glossina  morsitans.  To  prevent 
these  flies  from  having  access  to  sources  of  infection  like 
human  beings,  or  to  animals  that  harbor  the  disease,  is  the 
next  step  in  order  of  importance.  Wild  animals  probably  are 
reservoirs  of  infection.  Duke"''*'  has  found  the  Trypanosoma 
gambiense  in  two  marsh  antelopes.  Up  to  the  present  time 
infected  flies  have  been  found  only  in  Africa  within  a  few 
degrees  of  the  Equator.  The  greatest  precautions  should  be 
taken  with  persons  infected  with  the  disease  who  come  into 
regions  in  which  the  tsetse  fly  occurs,  to  the  end  that  new 
centers  of  infection  may  not  develop. 

The  course  of  the  disease  readily  divides  itself  into  three 
stages:  the  incubation,  the  febrile  or  glandular,  and  the  cere- 
bral. The  incubation  period  is  not  known.  Various  authors 
agree  that  the  disease  is  most  likely  to  occur  within  from  ten 
days  to  two  weeks  after  the  bite  of  the  fly.  In  Europeans 
the  onset  of  the  disease  begins  with  fever  associated  with  an 
erythematous  eruption.  The  fever,  which  may  be  intermit- 
tent or  remittent,  lasts  for  about  a  week,  and  then  disappears 
without  treatment,  only  to  occur  for  the  same  or  much  longer 


288  TROPICAL   DISEASES. 

periods.  The  eruption  in  Europeans  begins  with  badly  de- 
fined pinkish  patches,  which  gradually  fade  in  the  center  until 
only  a  margin,  or  ring,  is  left.  The  eruption  may  appear  upon 
any  part  of  the  body,  although  it  is  most  frequently  found  on 
the  trunk.  It  is  very  difficult  to  recognize  the  typical  ery- 
thema in  negroes. 

After  a  febrile  stage,  which  may  have  lasted  for  some 
weeks,  months,  or  sometimes  even  years,  a  change  becomes 
noticeable  in  the  habits  and  disposition  of  the  patient.  Those 
who  previously  have  been  active  show  disinclination  for  exer- 
tion and  prefer  to  sit  quietly  or  lie  down.  This  is  followed 
by  careless  habits  and  difficulty  in  walking.  Then  the  actual 
sleeping  stage  begins.  The  sleep  may  be  excessive,  but  it  is 
not  necessarily  the  prominent  symptom  so  often  described. 
It  is  more  of  a  lethargy  from  which  the  patient  can  be 
roused,  and,  despite  the  obvious  somnolence  of  the  subject, 
questions  are  answered  intelligently.  Fine  tremors  may  be 
noticed  first  in  the  tongue,  and  later  in  the  hands,  arms,  and 
sometimes  in  the  legs ;  occasionally  the  tremors  are  so  severe 
that  the  whole  body  shakes.  There  is  usually  fever,  the  tem- 
perature rising  in  the  evening  from  100°  to  104°  F.  (37.7°  to 
40°  C).  The  gait  is  peculiar,  there  being  apparent  difficulty 
in  raising  the  feet,  but  there  is  seldom  paralysis ;  superficial 
reflexes  are  normal  at  first;  the  deep  reflexes  may  be  in- 
creased, and  then  completely  lost ;  there  is  frequently  a  grad- 
ual reduction  in  the  number  of  erythrocytes  to  2,000,000  per 
culjic  millimeter,  or  even  less,  although  occasionally  a  case  is 
encountered  in  which  there  is  an  increase  in  the  number  of 
red  cells.  The  demonstration  of  the  trypanosomes  in  the 
blood  furnishes  conclusive  evidence  of  the  presence  of  the 
disease. 

When  the  disease  is  due  to  the  Trypanosoma  rhodesiense  it 
usually  runs  a  rapid  course,  and  is  generally  fatal  within  four 
or  five  months.  When  due  to  the  Trypanosoma  gamhiense  it 
may  last  a  number  of  years.  Complications  such  as  malaria, 
filaria,  intestinal  parasites,  and  cerebrospinal  meningitis  are 
common. 

The  diagnosis  depends  upon  finding  the  trypanosomes  in 
the  blood.  The  endemic  areas  in  which  the  disease  is  found; 
the  fever  which  does  not  yield  to  quinin;  the  fine  tremor  of 


HOOKWORM    INFECTION.  289 

the  tongue,  and  the  drowsiness,  the  apathy,  and  later  the  gen- 
eralized tremors  are  significant. 

The  prognosis  in  untreated  cases  is  nearly  always  fatal. 
Recently  considerable  success  has  been  had  in  the  treatment 
of  the  disease  with  various  preparations  of  arsenic,  and  espe- 
cially atoxyl. 

TREATMENT. 

Hanson's  method  of  administering  atoxyl  in  2-  or  3-  grain 
(0.13  or  0.19  Gm.)  doses  by  intramuscular  injection  every 
third  day  for  two  years  offers  the  best  hope  of  recovery. 
Some  patients  show  considerable  chemoresistance,  which  is 
apparently  due  to  the  fact  that  trypanosomes  become  resistant 
after  a  prolonged  use  of  the  same  drug.  On  this  account 
various  modifications  of  administering  the  arsenic  have  been 
suggested.  It  has  been  found  useful  to  supplement  the  atoxyl 
with  2  grains  (0.13  Gm.)  of  sodiotartrate  of  antimony  dis- 
solved in  2  pints  (1  1.)  of  water  and  administered  by  mouth 
or  rectum.  Mercury  has  also  been  used  with  apparent  suc- 
cess. If  there  is  coincident  malaria  or  infection  with  intestinal 
parasites,  appropriate  treatment  also  must  be  given  for  these. 

HOOKWORM    INFECTION. 

Hookworm  infection  is  an  infestation  of  the  human  ali- 
mentary tract  with  small  nematode  worms  which,  in  many 
instances,  are  responsible  for  severe  anemia  and  for  other  con- 
stitutional disturbances.  Under  the  term  hookworm  have 
been  included  the  infections  caused  by  Ancylostoma  duodcnalc 
(Dubini)  and  those  due  to  the  Necator  americanus  (Stiles). 
In  the  Eastern  countries  it  is  customary  to  refer  to  infections 
due  to  either  of  these  worms  as  ancylostomiasis,  although  a 
strict  definition  of  the  terms  would  restrict  ancylostomiasis  to 
infections  caused  by  the  ancylostome.  On  the  Western 
Continent  it  is  customary  to  refer  to  either  of  the  infections 
as  hookworm  disease  or  uncinariasis. 

There  are  indefinite  references  to  a  disease  which  may 
have  been  due  to  hookworm  infection  as  early  as  1550  b.  c. 
In  the  New  World,  Piso,  in  1648,  in  his  history  described  a 
fatal   disease    in    Brazil   which    may   have    been    uncinariasis. 

19 


290  TROPICAL   DISEASES. 

Frequent  references  occur  to  a  disease  resembling-  uncinariasis 
by  various  authors  of  books  relating  to  Santo  Domingo, 
Jamaica,  British  Guiana,  and  as  early  as  1808  in  the  United 
States.  It  was,  however,  not  until  1843,  when  Dubini,  in 
Italy,  found  the  Ancylostoma  diiodenale  as  the  cause  of  miners' 
anemia,  that  the  diagnosis  of  the  disease  was  placed  upon  a 
definite  basis. 

Bilharz-58  recognized  the  disease  in  Egypt  in  1852,  Wuch- 
erer59  in  1872  in  Brazil.  In  1902  Stiles^o  described  the  Necalor 
americanus  found  in  the  Southern  States  as  a  new  species  of 
the  worm.  In  the  same  year  Boycott  and  Haldane^i  found  the 
disease  among  miners  in  Cornwall,  England.  In  1898  Loos 
traced  the  method  of  infection  through  the  skin,  blood-ves- 
sels, lungs,  trachea  and  esophagus  to  the  intestinal  tract.  In 
1899  Ashford^^  drew  attention  to  the  great  prevalence  of  the 
disease  in  Porto  Rico,  and  the  high  eosinophilia.  Soon  after- 
ward a  large  number  of  examinations  made  in  Porto  Rico  by 
Ashford,^'^  and  in  the  United  States  by  Stiles,^*  showed  that 
there  was  a  high  incidence  of  infection  among  the  residents 
of  Porto  Rico  and  of  the  Southern  States  of  the  United  States. 
These  writings  attracted  much  popular  attention,  and  public- 
health  measures  were  undertaken  on  a  large  scale  for  the  con- 
trol of  uncinariasis.  These  measures  were  particularly  diffi- 
cult of  application  in  the  United  States,  because  of  the 
attitude  that  it  was  rather  a  reflection  on  a  community  to 
admit  the  presence  of  this  disease.  This  feeling  was  accen- 
tuated by  the  fact  that  the  disease  was  associated  with  clay- 
eating,  and  also  because  the  Press  frequently  referred  to  the 
infection  as  the  lazy  worm.  The  excellent  work  done  in  Porto 
Rico,  however,  soon  resulted  in  convincing  the  public  of  the 
great  importance  of  the  disease,  and  of  the  improved  health 
which  followed  when  measures  for  its  control  were  actively 
undertaken.  It  was  soon  very  generally  recognized  that 
hookworm  infection  was  intimately  associated  with  anemia, 
and  especially  the  very  debilitating  disease  known  as  tropical 
anemia. 

In  1909  the  Rockefeller  Sanitary  Commission  was  organ- 
ized with  a  fund  of  $1,000,000,  for  the  purpose  of  attempting 
the  control  and  the  relief  of  the  disease  in  the  Southern 
States   of  America.      Practical  work  was  begun   in    1910  in 


HOOKWORM    INFECTION.  291 

co-operation  with  State  and  local  health  departments  or  other 
officials  where  no  health  officers  were  available,  and  the  suc- 
cess achieved,  especially  in  winning  popular  approval,  not 
only  for  measures  directed  against  hookworm  infections,  but 
also  for  public  health  measures  in  general,  has  resulted  in  one 
of  the  notable  advances  in  the  public-health  movement  which 
is  now  making  such  rapid  progress  throughout  the  civilized 
world.  In  1913  the  International  Health  Commission  was 
organized  under  the  Rockefeller  Foundation.  It  has  for  its 
object  the  relief  and  control  of  hookworm  infection  through- 
out the  tropical  world.  The  enormous  magnitude  of  this  plan 
may  be  well  appreciated  when  it  is  recalled  that  hookworm 
disease  occurs  in  practically  all  countries  at  altitudes  below 
3000  feet  and  between  36  degrees  north  latitude  and  30  degrees 
south  latitude. 

Hookworm  surveys  made  during  the  past  few  years 
throughout  the  world  show  that  the  disease  is  even  more 
prevalent  than  was  at  first  anticipated.  Recently  (1916)  some 
thousands  of  examinations  made  in  Ceylon  showed  an  infec- 
tion of  96  per  cent.  It  is  very  rare  not  to  find  at  least  a  10 
per  cent,  infection.  The  percentage  of  the  infection  may  be 
said  to  depend  upon  the  effectiveness  with  which  human 
excrement  is  disposed  of.  A  great  feature  in  the  introduction 
and  spread  of  hookworm  disease  into  areas  heretofore  free 
from  infection  has  been  the  emigration  of  labor  from  India. 
For  instance,  the  migration  of  the  Tamils  from  Southern  India 
to  the  West  Indies,  Ceylon,  Federated  Malay  States,  and  the 
Fiji  Islands  has  resulted  in  an  infection  rate  which  is  prob- 
ably hig"her  than  existed  in  the  sections  of  India  from  which 
they  came.  This  is  largely  traceable  to  the  fact  that  these 
emigrants  are  generally  employed  in  agricultural  operations, 
and  are  closely  housed  in  barrack  buildings,  which  are  seldom 
supplied  with  adequate  latrine  accommodation.  This  has 
resulted  in  much  concentrated  soil  pollution,  and  as  these 
laborers  practically  always  go  barefooted,  there  is  practically 
no  obstacle  to  their  contracting  repeated  hookworm  infec- 
tions. The  disease  is  confined  almost  entirely  to  a  belt 
around  the  earth  inclosed  between  latitude  36°  north  and  lati- 
tude 30°  south,  but  even  in  this  tropical  belt  tliere  is  a  marked 
reduction  in  the  incidence  of  infections  when  an  altitude  of 


292  TROPICAL   DISEASES. 

3000  feet  and  above  is  reached.  In  many  high  altitudes  the 
disease  is  not  found,  and  this  comparative  freedom  of  infec- 
tion is  probably  due  to  the  fact  that  the  lower  temperatures 
(cooler  weather  conditions)  which  prevail  at  higher  altitudes 
are  inimical  to  the  development  of  the  larval  stage  of  the 
hookworm.  However,  hookworm  infections  often  do  occur  at 
high  altitudes,  and  the  small  amount  of  infection  found  may 
be  due  to  the  lack  of  introducing  the  infection.  It  is  worthy 
of  note  that  there  are  large  tropical  districts  in  which  the  dis- 
ease does  not  exist,  or  at  least  prevails  to  a  very  slight  extent, 
examples  of  such  districts  being  the  Bombay  Presidency  and 
the  Punjab  in  India.  At  first  sight  this  might  appear  to  be 
due  to  the  hot,  dry  conditions  which  prevail,  but  under  similar 
conditions  in  Egypt,  where  it  is  equally  dry  and  hot,  50  per 
cent,  hookworm  infections  have  been  found.  It  is  reasonable 
to  assume  that  much  of  this  difiference  in  the  infection  rate 
may  be  due  to  the  safer  method  of  human  excrement  disposal, 
and  to  the  small  number  of  infected  persons  who  are  intro- 
duced into  the  Punjab. 

The  disease  is  caused  by  the  presence  of  the  Ancylostoma 
duodenale  or  the  Necator  americanuis  in  the  intestines.  So  far 
as  known,  these  parasites  live  only  in  human  beings.  The 
Ancylostoma  ceylonense  is  commonly  found  in  dogs,  but  there 
is  no  evidence  to  show  that  they  may  live  in  the  human  intes- 
tines. The  cause  of  the  symptoms  which  the  disease  produces 
has  not  yet  been  satisfactorily  demonstrated.  Some  authors 
believe  that  the  symptoms  are  due  to  toxins  set  free  by  the 
embryo  in  its  travels  from  the  skin  to  the  alimentary  canal. 
Others  believe  them  due  to  toxins  given  off  by  the  adult  worm 
after  it  has  reached  the  intestines. 

The  points  at  which  the  embryos  entered  the  skin  in  suffi- 
cient numbers  usually  show  an  eruption  of  papules  or  vesicles, 
which,  in  all  probability,  are  due  to  skin  infections  by  bacteria 
introduced  through  the  larvae.  The  skin  lesions  are  called 
Ground  Itch  in  Assam  and  other  English-speaking  countries, 
and  Mazamorra  in  Spanish  countries.  It  has  been  shown  that 
the  entrance  of  the  larvse  is  attended  by  itching  and  a  macular 
eruption,  followed  the  next  day  by  swelling  of  the  part. 
Usually  five  days  afterward  there  is  an  enlargement  of  the 
lymph-glands  of  the  affected  areas,  and  the  eruption  usually 


HOOKWORM    INFECTION.  293 

disappears  by  the  twelfth  day.  Observers  in  many  countries 
have  reported  that  they  are  unable  to  associate  ground  itch 
w^ith  hookworm  infection.  It  may  be  stated,  however,  that 
when  careful  observation  is  possible,  ground  itch  is  usually 
found.  The  patient  usually  fails  to  recall  the  eruption,  which 
fact  is  probably  due  to  the  long  time  which  elapses  between 
the  eruption  and  the  appearance  of  symptoms.  The  ova 
usually  appeared  in  stools  six  weeks  after  the  original  infec- 
tions took  place. 

Still  others  believe  that  the  symptoms  are  due  to  the 
anemia  caused  by  the  hemorrhages  produced  by  the  parasite 
when  it  feeds  on  the  walls  of  the  intestines.  It  was  also 
thought  that  perhaps  the  infected  wounds  resulting  from  the 
bites  of  the  parasite  may  be  responsible  for  a  toxemia  which 
causes  destruction  of  the  erythrocytes. 

There  is  not  much  evidence  of  racial  immunity,  except  in 
so  far  as  it  concerns  the  custom  of  going  barefooted  or  other 
habits  that  lead  to  infection.  In  Porto  Rico,  for  instance, 
there  was  an  infection  of  71  per  cent,  among  the  Europeans, 
54  per  cent,  among  mulattoes,  and  41  per  cent,  among  negroes. 
In  Ceylon  the  reverse  held  true,  there  being  a  90  per  cent, 
infection  among  Tamils  and  20  per  cent,  infection  among 
Europeans.  It  seems  quite  probable  that  these  differences 
can  be  reconciled  by  the  difference  in  the  soil  pollution  and 
personal  habits  of  the  various  races,  in  the  particular  place  in 
which  the  observation  was  made. 

There  is  no  general  agreement  as  to  whether  the  larvre 
produce  symptoms  in  the  patient  during  the  passage  from 
the  skin  to  the  alimentary  canal,  but  soon  after  the  worms 
reach  the  alimentary  tract  in  sufficient  numbers  marked 
reductions  in  the  hemoglobin  and  other  blood  changes  take 
place.  The  anemia  is  ascribed  by  Castellani'""'  to  "hemolytic 
toxins  secreted  by  the  worm,  actual  loss  of  blood  from  the 
bites  of  the  worm,  and  microbic  secondary  infections." 

Edema  of  the  feet  and  a  white  appearance  of  the  conjunc- 
tiva may  be  noted  on  inspection  of  the  body.  The  intestines 
are  pale,  the  peritoneum  is  saturated  and  heaw,  and  some 
straw-colored  fluid  is  generally  found  in  the  peritoneal  cavity. 
All  of  the  organs  appear  damp  and  pale.  The  lungs  are 
edematous,  the  heart  is  pale  and  fatty,  and  sometimes  there 


294  TROPICAL    DISEASES. 

is  hypertrophy  of  the  left  ventricle.  The  liver  is  fatty.  The 
spleen  is  usually  shrunken.  The  pancreas  and  super-renal 
glands  are  normal.  The  kidneys  are  often  enlarged,  pale  and 
fatty.  The  jejunum  and  ileum  frequently  show  ecchymotic 
areas  w^hich  were  caused  by  the  bites  of  the  hookworm.  The 
stomach  may  show  evidence  of  chronic  indigestion.  Hook- 
worms varying  from  a  few  to  as  many  as  3000  are  found  in 
the  jejunum  and  ileum. 

The  Ancylostoma  duodenale  has  a  cylindrical  body  which 
tapers  from  the  back  to  the  front  in  both  sexes.  During  life 
it  is  pinkish  red  in  color.  The  mouth  is  terminal.  On  its 
under  side  it  has  two  pairs  of  hook-like  teeth,  and  on  the 
upper  or  dorsal  side  one  pair  of  teeth.  The  male  measures 
about  10  millimeters  (%  in.)  in  length  and  0.4  to  0.5  milli- 
meter (0.016  to  0.02  in.)  in  breadth.  The  female  measures 
12  to  13  millimeters  (0.48  to  0.52  in.)  in  length,  and  has  a 
vulva  at  the  junction  ofi  the  middle  with  the  after-third  of 
the  body.  The  male  generative  apparatus  consists  of  a  testis 
in  the  form  of  a  tube,  an  oval  vesicula  seminalis,  and  a  gland 
which  exudes  a  sticky  substance  to  fix  the  male  to  the  female 
during  conjugation. 

The  Necator  americanus  has  a  cylindrical  body  which  is 
somewhat  smaller  in  diameter  at  its  anterior  part.  The  head 
is  usually  bent  acutely  on  its  dorsum.  The  mouth  has  a 
ventricular  pair  of  prominent,  semilunar,  chitinous  plates  and 
a  dorsal  pair  of  plates  slightly  developed.  In  the  floor  of  the 
mouth  the  dorsal  head  gland-opening  resembles  a  conical 
tooth,  and  deeper  in  the  cavity  there  are  a  pair  of  dorsal  and 
a  pair  of  submedian  lancets.  There  is  an  excretory  pore  at 
0.5  millimeter  (0.02  in.)  behind  the  mouth.  The  male  meas- 
ures from  7  to  9  millimeters  (0.28  to  0.36  in.)  in  length  and 
from  0.3  to  0.5  millimeter  (0.012  to  0.02  in.)  in  breadth.  The 
female  is  9  to  12.6  millimeters  (0.36  to  0.504  in.)  in  length. 

Practically,  the  two  parasites  may  be  readily  distinguished, 
first,  by  their  size,  and,  second,  when  they  are  dropped  into 
hot  alcohol,  the  Ancylostoma  duodenale  resembles  an  elon- 
gated letter  S,  whereas  the  Necator  americanus  resembles  a 
cane  with  a  crook  upon  it,  as  shown  in  the  accompanying 
illustration. 

The  fidult  worms  are  chiefly  found  in  the  jejunum  of  the 


HOOKWORM    INFECTION.  295 

human  host,  where  they  feed  upon  the  villi.  Here  the  females 
lay  their  eggs,  which  are  oval  in  form,  with  broad,  rounded 
poles  surrounded  by  a  colorless  shell  which  incloses  a  gran- 
ular mass  separated  from  the  shell  by  a  considerable  space. 
As  the  eggs  travel  down  the  intestinal  tract  the  granular  mass 
divides  into  two  and  usually  into  four  segments,  which  is  the 
condition  in  which  the  egg  is  usually  found  in  the  feces.  The 
rapidity  of  the  development  in  the  feces  depends  upon  the 
temperature  of  the  atmospheric  air.  When  conditions  are 
favorable  as  to  air,  water  and  heat,  the  embryo  may  be  seen 
coiled  up  in  the  egg  twenty-four  hours  after  it  has  been 
voided.  It  then  escapes  as  a  larva  and  feeds  on  fecal  matter. 
The  larva  is  needle-shaped,  running  to  a  point  posteriorly, 
and  measures  from  200  to  250  microns  in  length.     In  the 

/  f 

Ancylostoma  duodenale.  Necator  americaiuts, 

tropics  at  the  end  of  five  days  it  ceases  to  grow,  and,  feeding 
on  feces,  it  sticks  to  the  water  or  moist  earth,  where  it  may 
remain  unchanged  for  months,  living  on  the  food-matter 
inclosed  in  its  own  cell.  This  represents  the  encysted  stage. 
The  larva  may  become  quite  active  and  swim  and  climb  on 
wet  surfaces.  During  this  period  it  is  ready  to  infect  man, 
which  it  does  usually  through  the  hair-follicles  in  the  skin, 
causing  eruption  or  sores  commonly  called  ground  itch.  From 
the  hair-follicles,  according  to  Loos,^^  it  forces  its  way  through 
the  subcutaneous  tissue  into  the  veins  and  lymphatics.  Those 
which  have  entered  a  vein  go  to  the  right  heart  and  thence 
to  the  lungs.  If  the  larvse  have  entered  the  lymph-channels 
many  are  killed  in  the  lymphatic  glands,  but  some  get  through 
to  the  blood  and  are  carried  to  the  lungs.  In  the  lungs  they 
penetrate  the  capillaries,  reach  the  air-cells,  travel  up  the 
bronchi  to  the  trachea  and  larynx,  and  then  descend  the 
esophagus.  The  time  occupied  by  this  migration  is  generally 
believed  to  be  ten  days.  After  the  fourth  day  ecdysis  takes 
place  in  the  alimentary  canal,  which  change  occurs  from  eight 


296  TROPICAL   DISEASES. 

to  ten  days  after  their  arrival ;  they  then  measure  3  to  5  milli- 
meters (0.12  to  0.2  in.)  in  length.  Eight  days  later  the  gen- 
erative organs  begin  to  attain  maturity,  and  then  first  copula- 
tion takes  place.  A  few  days  later  eggs  appear  in  the  feces, 
so  that  from  the  time  infection  in  the  skin  took  place  until 
eggs  are  found  in  the  human  stool  a  period  of  four  to  six 
weeks  elapses. 

Sambon^"  believes  that  some  of  the  larvse  may  follow  the 
route  indicated  above,  but  that  infection  also  takes  place  by 
the  larvse  passing  from  the  pulmonary  artery  to  the  pulmo- 
nary vein,  whence  they  are  carried  by  the  blood  to  the 
jejunum,  which  they  penetrate  and  enter  the  lumen  of  the 
bowel.  Sambon  also  believes  that  when  larvse  are  taken 
directly  into  the  mouth  they  probably  pierce  the  walls  of  the 
esophagus  and  reach  the  intestinal  tract  by  the  way  of  the 
blood-vessels,  in  exactly  the  same  way  as  if  they  had  orig- 
inally penetrated  the  skin. 

Usually  the  first  symptom  is  a  dermatitis  of  the  feet  and 
legs,  and  when  it  affects  the  sole  of  the  feet  it  is  commonly 
known  as  sore  feet  of  coolies  and  also  as  ground  itch.  Con- 
siderable itching  is  generally  present  in  these  lesions.  The 
onset  of  the  disease  in  the  great  majority  of  instances  is  most 
insidious.  Many  persons  are  afflicted  with  hookworm  infec- 
tion without  having  enough  symptoms  to  attract  attention. 
Slight  digestive  disturbances  are  common.  Others  become 
anemic  a  few  weeks  after  the  parasites  reach  the  intestines, 
and  leucocytosis  with  eosinophilia  is  the  rule.  Anemia  is 
probably  the  most  common  symptom.  The  pearly  whiteness 
of  the  conjunctiva  and  the  white  finger-nails  are  characteris- 
tic, and  when  once  seen  are  seldom  forgotten.  The  peculiar 
suffusion  of  the  countenance  soon  leads  even  laymen  to  sus- 
pect the  disease.  The  feet  and  ankles  are  dropsical.  There 
is  usually  emaciation,  but  this  is  often  concealed  by  the 
dropsy.  In  many  cases  there  is  only  edema  of  the  feet,  while 
in  others  it  may  extend  to  the  legs,  scrotum  and  face,  and  be 
associated  with  ascites.  In  the  Fiji  Islands  a  black  tongue 
has  been  associated  with  hookworm  infection,  but  examina- 
tions of  natives  who  were  not  afflicted  with  hookworm  dis- 
ease showed  black  tongue  in  almost  similar  proportions. 
Often  there  is  chronic  dyspepsia,  due  to  gastritis,  and  marked 


HOOKWORM    INFECTION.  297 

by  nausea  and  pain  over  the  stomach.  There  may  be  diarrhea 
or  constipation.  There  is  usually  a  marked  reduction  in  the 
percentage  of  hemoglobin,  which  sometimes  drops  to  10  per 
cent,  before  the  patient  succumbs  to  the  disease.  The  blood 
condition  often  resembles  that  found  in  chlorosis.  The  blood- 
picture  is  almost  the  reverse  of  that  found  in  pernicious 
anemia.  The  eosinophilia  averages  about  10  per  cent.  In  a 
well-marked  case  the  erythrocytes  may  be  reduced  to  a  mil- 
lion, with  a  normal  leucocyte  count.  Patients  frequently 
complain  of  palpitation  of  the  heart  and  difficulty  in  breath- 
ing. The  vessels  of  the  neck  are  frequently  seen  to  palpitate 
in  a  very  marked  manner.  The  pulse  is  usually  quick,  weak, 
thready,  dicrotic,  and  sometimes  intermittent.  In  children 
enlargement  of  the  liver  is  frequent.  In  many  cases  there  is 
a  low  intermittent  type  of  fever  in  which  the  temperature 
seldom  rises  to  about  38°  C.  (100.5°  F.).  Some  cases  present 
various  modifications  in  the  temperature  feature,  and  fre- 
quently it  is  difficult  to  distinguish  hookworm  fever  from 
malarial  fever,  kala-azar  and  trypanosomiasis.  The  urine  is 
usually  copious,  pale,  and  often  alkaline,  with  a  specific 
gravity  varying  from  1.010  to  1.015;  albumin  is  rare,  but  there 
may  be  an  increase  of  indican  and  urobilin. 

Mental  and  physical  hebitude  may  be  marked,  and  this  has 
frequently  been  referred  to  in  the  popular  press  as  a  symptom 
due  to  the  lazy  worm.  It  often  happens  that  laborers  who 
have  rested  are  quite  capable  of  performing  their  ordinary 
tasks  on  Monday,  being  less  able  on  Tuesday,  and  by 
Wednesday  afternoon  they  are  completely  exhausted,  and 
must  rest  until  the  following  Monday  before  being  able  to 
resume  their  tasks.  When  anemia  becomes  extreme,  death 
may  result  from  heart-failure ;  but  it  not  infrequently  happens 
that  death  is  due  to  some  intercurrent  aft'ection. 

A  definite  diagnosis  of  hookworm  infection  depends  upon 
finding  the  ova  or  the  adult  w^orms  in  the  stools.  The  follow- 
ing method  has  recently  been  devised  by  Barber,'^^  and  appar- 
ently resulted  in  finding  the  hookworm  eggs  with  greater 
certainty  than  is  the  case  by  the  ordinary  microscopic  technic 
heretofore  employed. 

Field  workers  investigating  uncinariasis  may  desire  to 
learn  of  a  convenient  method  by  which,  without  the  aid  of  a 


298  TROPICAL   DISEASES. 

centrifug-e,  from  70  per  cent,  to  90  per  cent,  of  the  positive 
cases  of  hookworm  infection  can  be  expeditiously  detected. 
Dr.  M.  A.  Barber,  who  has  furnished  the  following  particulars 
of  the  method,  recommends  its  use,  when  it  is  anticipated  that 
the  percentage  of  positive  cases  will  be  high  (80  per  cent,  to 
90  per  cent.).  He  estimates  that  by  its  use,  together  with 
that  of  the  centrifuge  in  the  remaining  apparently  negative 
cases,  100  to  150  specimens  can  be  examined  per  diem  by  one 
microscopist. 

The  details  of  the  method,  which  depends  primarily  on 
the  different  specific  gravities  of  the  hookworm  ova  and  a 
mixture  of  glycerin  and  saturated  NaCl,  are  as  follows : 

1.  The  feces  (preferably  a  fair  quantity)  in  a  convenient 
container,  such  as  a  half  cocoanut-shell  or  latex  cup,  are  thor- 
oughly stirred  with  a  small  flexible  stick,  to  obtain  an  even 
distribution  of  ova  through  the  mass,  water  being  added  if 
necessai-y,  to  form  a  smooth,  soft  paste. 

2.  Slides  either  3x1  or  3  x  2  inches  (7.6x2.5  cm.  or  7.6  x 
5.0  cm.),  properly  labeled,  are  prepared  by  drawing  around 
the  margin  of  the  upper  surface  a  broad  line  with  a  grease 
pencil  or  paraffin. 

3.  A  small  portion  of  the  fecal  mass  is  placed  upon  the 
slide,  and,  with  the  aid  of  a  small  stick  or  similar  appliance, 
is  thoroughly  stirred  into  a  mixture  of  equal  parts  of  glycerin 
and  saturated  NaCl  solution  dropped  on  to  the  slide.  The 
mixture  on  the  slide  should  be  of  such  volume  as  almost  to 
overflow  the  greased  edge.  The  surface  of  the  fluid  will  be 
convex;  the  aim  is  to  add  as  much  fecal  matter  as  possible 
without  making  the  specimen  too  opaque  for  microscopic 
examination.  Practice  soon  shows  the  degree  of  opacity 
which  should  not  be  exceeded. 

4.  The  slides  now  ready  for  examination  are  placed  upon 
a  slideholder,  which  holds  from  ten  to  fifteen  slides,  a  rough 
sketch  of  which  is  given  herewith . 

The  preparations  are  examined  without  a  cover-glass. 
Owing  to  the  higher  specific  gravity  of  the  glycerin  and  salt 
solution,  the  ova  float  to  the  surface,  and  are  easily  detected 
with  a  low-power  lens. 

The  objective  should  be  focused  to  the  surface  level  and 
not  to  the   depth   of  the   fluid.     The  preparation   should  be 


HOOKWORM    liNFECTION.  299 

examined  within  an  hour  or  so,  otherwise  hyaline  ova  may 
become  too  transparent  for  easy  recognition. 

5.  In  the  event  of  the  first  centrifuge  search  of  the  appar- 
ently negative  specimens  proving  negative  in  any  case,  a 
second  fecal  specimen  obtained  on  a  subsequent  day  should 
be  examined. 

Observers  who  have  had  considerable  experience  with 
hookworm  disease  soon  acquire  the  ability  to  make  reason- 
ably accurate  diagnosis  by  the  typical  facial  appearance. 
This  is  difficult  to  describe,  and  probably  can  only  be  learned 
by  practice.  Some  of  the  principal  points  concerned,  how- 
ever, are  the  muddy  complexion  in  whites,  the  suffused  fea- 
tures, the  extreme  whiteness  of  the  conjunctiva,  and  the  tired 
expression.     The  foregoing  facies  associated  with  indefinite 


L 


Fig.  11. — A  thin  board  large  enough  to  carry  ten  slides  or 
more  is  used,  small  cleats  I/2  in.  x  ><  in.  (12.7x12.7  mm.) 
wood  being  fixed  at  both  ends  of  the  underside  of  the  board. 
This  enables  the  holders  to  be  stacked  if  desired. 

abdominal  pains,  swelling  of  the  feet,  extreme  pallor  of  the 
finger-nails,  and  slight  irregular  fever  should  always  be  fol- 
lowed by  a  search  for  adult  worms,  and  by  a  careful  micro- 
scopic examination  of  the  feces  for  hookworm  eggs.  The 
adult  worms  can  be  recovered  readily  by  washing  the  stools 
through  cheesecloth  or  fine  muslin. 

TREATMENT. 

The  number  of  treatments  which  have  been  advocated  are 
legion.  During  the  past  few  years  scientific  field  work  has 
done  much  to  bring  order  out  of  the  chaos.  The  Hookworm 
Board  of  the  Rockefeller  Foundation  (Darling,  Barber  and 
Hacker),  which  has  been  working  in  the  Federated  Malay 
States  during  1915  and  1916,  has  made  careful  tests  of  many 
remedies  which  have  been  advocated.  It  has  come  to  the 
conclusion  that  oil  of  chenopodium  shows  an  efficiency  of  92 
per  cent,  as  compared  with  82  per  cent,  for  thymol,  60  per 


300  TROPICAL   DISEASES. 

cent,  for  betanaphthol  and  40  per  cent,  for  eucalyptus.  The 
chenopodium  method  used  closely  resembles  that  advocated 
by  Shiiffner,  Kunen,  Vervoort  and  others  in  Sumatra,  who 
have  reported  the  treatment  of  over  300,000  cases.  The 
method  used  by  the  board  of  the  Malay  States  consists  of 
g-iving  the  patient  liquid  diet  and  a  cathartic  dose  of  mag- 
nesium sulphate,  next  morning-  no  breakfast,  but  a  cup  of  tea 
may  be  permitted.  At  7  o'clock  a  gram  (15.4  grs.)  of  oil  of 
chenopodium,  followed  by  a  similar  dose  at  8  o'clock  and  at 
9  o'clock,  or  a  total  of  3  grams  (46.3  grs.),  and  at  11  o'clock 
a  cathartic  dose  of  magnesium  is  given.  It  has  been  found 
that  the  dead  worms  continued  to  be  voided  for  several  days, 
and  usually  80  per  cent,  of  the  total  is  voided  by  the  second 
day,  and  up  to  93  per  cent,  on  the  third  day.  Many  instances 
have  been  reported  in  the  literature  of  oil  of  chenopodium 
producing  toxic  effects,  but  in  such  instances  usually  a  much 
larger  dose  than  the  foregoing  has  been  administered.  There 
is  also  much  reason  to  believe  that  chenopodium  may  have  a 
cumulative  effect,  and  it  is  considered  very  unwise  to  admin- 
ister the  treatment  continuously  for  a  number  of  days,  even 
in  small  doses.  Purgative  action  after  chenopodium  has  been 
given  is  essential.  After  a  treatment  has  been  given  it  should 
not  be  repeated  for  at  least  ten  days.  The  dose  given  above 
should  be  reduced  proportionately  for  children.  There  are, 
however,  still  many  advocates  of  the  thymol  treatment.  The 
system  used  by  the  various  commissions  working  in  many 
countries  in  co-operation  with  the  International  Health  Board 
of  the  Rockefeller  Foundation  is  as  follows : 

"1.  On  the  day  preceding  the  treatment  give  a  large  dose 
of  sulphate  of  magnesia  at  5  p.m.  No  supper  should  be  eaten. 
The  saline  should  thoroughly  empty  the  alimentary  canal. 

"2.  Remain  in  bed  the  following  morning  without  food. 

"3.  At  6  A.M.  take  one-half  of  the  thymol;  at  8  a.m.  take 
the  remainder. 

"4.  Take  a  large  dose  of  sulphate  of  magnesia  at  11  a.m. 
This  should  be  repeated  if  a  thorough  movement  of  the 
bowels  is  not  secured  within  two  hours. 

"5.  No  food  should  be  taken  until  after  the  bowels  have 
moved  thoroughly,  and  then  no  greasy  foods,  milk,  alcoholics 
or  malt  drinks  should  be  indulged  in. 


HOOKWORM    INFECTION.  301 

"6.  The  usual  diet  and  habits  may  be  resumed  on  the  day 
following  treatment. 

"7.  If  the  patient  feels  weak  or  dizzy  during  the  treatment 
give  Yz  cup  of  strong  coffee  without  sugar  or  milk. 

"8.  Careful  examination  of  the  dejecta  from  the  second 
dose  of  sulphate  of  magnesia  should  show  the  dead  worms 
expelled. 

"9.  Several  of  these  courses  of  thymol,  given  at  weekly 
intervals,  are  usually  necessary  for  cure." 

Various  methods  have  been  suggested  for  administering 
the  oil  of  chenopodium.  Schiiffner^^  has  recommended  drop- 
ping the  oil  into  lumps  of  sugar;  others  have  used  gelatin 
capsules.  Where  large  numbers  of  persons  are  to  be  treated, 
the  capsule  method  is  probably  the  most  convenient,  and 
there  is  no  reason  to  believe  that  it  is  less  effective  than  other 
methods  of  administration. 

Prevention.  In  many  respects  uncinariasis  is  one  of  the 
diseases  for  which  prophylactic  measures  may  be  applied  with 
the  greatest  hope  of  success.  The  life  history  of  the  parasite 
is  known ;  there  is  no  multiplication  in  the  human  host ;  the 
propagation  of  the  disease  takes  place  only  when  hookworm 
eggs  in  human  feces  are  deposited  upon  ground  surfaces  or 
in  other  places  where  later  the  resulting  larvae  may  come  in 
contact  with  the  human  skin,  or,  perhaps,  reach  the  mouth 
through  food,  water  or  other  means.  Briefly,  then,  multipli- 
cation of  the  parasite  takes  place  solely  outside  of  the  human 
body,  and  there  can  be  but  the  same  number  of  adult  para- 
sites in  the  human  intestines  as  there  have  larvae  penetrated 
the  skin  or  entered  the  throat  through  the  mouth  or  nose. 
The  treatment  of  the  disease  is  also  very  satisfactory,  so  that 
considerable  progress  toward  preventing  its  spread  can  be 
made  by  freeing  infected  persons  of  the  disease,  and  thus 
making  their  stools  safe,  even  though  excrement  disposal  is 
not  satisfactory.  Surveys  made  of  the  presence  and  spread 
of  the  disease  in  all  parts  of  the  world  show  that  it  exists  in 
those  tropical  regions,  and  in  mines  and  other  places  in  tem- 
perate zones  where  there  is  sufficient  warmth  and  moisture 
for  the  propagation  of  the  larvae  which  result  from  hookworm 
eggs  in  infected  stools  w^hich  have  been  allowed  to  cause  soil 
pollution.     Hookworm  infection  prevails,  for  instance,  much 


302  TROPICAL    DISEASES. 

more  extensively  in  small  towns  and  rural  districts  than  in 
large  cities,  this  being  due  to  the  safer  disposal  of  human 
excrement  in  cities.  Again,  the  disease  is  found  to  prevail 
very  extensively  upon  plantations  in  which  there  are  large 
numbers  of  laborers  who  are  closely  housed  and  pollute  the 
soil.  There  are  many  instances  which  show  that  through  the 
introduction  into  plantation  barracks  of  even  a  few  persons 
who  have  hookworm  disease  almost  the  entire  number  of 
laborers  soon  become  infected.  On  the  other  hand,  with 
similar  conditions,  but  with  safe  disposal  of  human  excre- 
ment, there  is  no  spread  of  the  disease.  Infection  in  mines 
and  tunnels  has  been  very  general,  especially  in  Europe, 
owing  to  the  fact  that  no  adequate  methods  for  the  disposal 
of  human  excrement  were  enforced.  Because  of  the  warmth 
and  the  moist  condition  of  the  soil  and  the  fact  that  usually 
there  is  flowing  water,  the  bottom  surfaces  of  the  mines  or 
tunnels  soon  become  thoroughly  infected  with  hookworm 
larvae,  and  even  the  wearing  of  boots,  shoes,  or  other  protec- 
tion for  the  feet  does  not  always  prevent  the  larvse  from 
reachine  the  skin  of  the  lower  extremities.  It  is  also  possible 
that  the  drinking-water  may  have  become  infected.  Some 
mines  have  been  found  remarkably  free  from  hookworm  in- 
fection, and  in  these  instances  examination  of  the  water 
showed  it  to  be  heavily  charged  with  iron  sulphate,  pyrites, 
or  other  chemicals.  It  has  been  found  that  ordinary  cinders 
are  inimical  to  the  development  of  the  larvse,  and  for  this  rea- 
son cinders  are  often  used  in  and  around  latrines,  so  that 
even  if  eggs  are  accidentally  deposited  their  development  will 
be  extremely  unlikely.  Briefly,  then,  the  prevention  of  the 
spread  of  uncinariasis  may  be  accomplished  by  water-carriage 
latrines,  by  collecting  excrement  in  deep  pits,  or  by  having  it 
"deposited  directly  into  fly-proof  pails,  and  then  incinerated  or 
buried  in  deep  trenches.  References  have  recently  appeared 
in  the  literature  in  regard  to  the  use  of  salt  for  the.  destruc- 
tion of  the  hookworm  eggs  and  larvse  in  human  excrement. 
Breinl'^^'  reports  that  this  method  has  proven  inefifective  in 
actual  practice.  Iron  sulphate  in  1  per  cent,  solution  has  been 
reported  upon  very  favorably.  In  l)rief,  however,  it  may  be 
stated  that  the  method  which  gives  the  greatest  hope  of  suc- 
cess is  the  proper  collection  and  safe  disposal  of  human  excre- 


THE    DYSENTERIES. 


303 


ment,  rather  than  dependence  upon  chemicals,  or  the  disin- 
fection of  the  stools  or  of  polluted  ground  surfaces.  Probably 
the  best  method  of  disposal  of  the  contents  of  pails  is  by 
incineration.  This  may  be  most  economically  accomplished 
on  plantations,  for  instance,  by  building  cylindrical  brick 
ovens  of  the  desired  capacity.  A  grate  is  placed  inside  the 
cylinder  about  18  inches  (45.7  cm.)  from  the  ground;  a  suit- 
able door  is  provided  above  it  for  the  wood  used  as  fuel,  and 
another  door  below  the  grate  for  removing  the  ashes.  The 
top  of  the  cylinder  is  left  open,  and  the  contents  of  the  pails 
are  dumped  into  the  top  after  the  fire  has  been  well  started. 
Ordinary  garbage  and  refuse  may  also  be  added,  and  assists 
in  the  burning.    See  illustration. 


«//- 


groLte 

»— -  •ash -  aooT' 


Fig.  12. — Incinerating  oven. 

Ovens  of  this  kind  have  been  used  successfully  in  Borneo 
and  other  Eastern  countries.  An  oven  for  the  needs  of  one 
hundred  people  can  be  constructed  for  about  $30. 


THE  DYSENTERIES. 

Until  very  recent  times  it  has  not  been  possible  to  make 
any  scientific  distinctions  between  the  different  dysenteries. 
This  was  particularly  true  of  amebic  and  l:)acillary  dysentery, 
but  the  great  progress  in  tropical  medicine  now  makes  it  pos- 
sible to  classify  them  into  those  caused  by  animal  parasites 
and  those  caused  by  bacteria. 

The  more  common  forms  of  dysentery  due  to  animal  para- 
sites are : 

1.  Amebic.  4.  Ciliar. 

2.  Laveranic.  5.  Helminthic. 

3.  Leishmanic.  6.  Balantidic. 


304  TROPICAL   DISEASES. 

Those  due  to  bacteria  are : 

1.  Bacillus  dysenterias.  4.  Flexner. 

2.  Hissbacillus  dysenterise.       5.  Castellani. 
.  3.  Shiga-Kruse. 

Dysentery  and  Diarrhea.  The  term  dysentery  as  distin- 
guished from  diarrhea  signifies  an  inflammation  of  the  bowel. 
Many  authors  distinguish  between  dysentery  and  diarrhea  by 
the  presence  of  blood  in  the  stool  of  the  former  and  by  its 
absence  in  the  latter.  It  is  frequently  referred  to  in  English 
as  bloody  flux,  in  French  as  tenesme,  in  Italian  as  Flusso  san- 
guigno,  and  in  German  as  rhur.  The  name  in  native  lan- 
guages usually  includes  words  which  mean  blood  and  mucus. 
Dysentery  is  a  disease  which  has  received  attention  by  med- 
ical writers  from  the  very  earliest  times.  Even  Hippocrates 
distinguished  between  motions  which  contained  blood  and 
those  which  consisted  of  other  fluid  matter. 

Protozoal  Dysenteries.  Protozoal  dysenteries  are  various 
forms  of  ill-defined  dysenteries  which  are  caused  by  protozoal 
parasites.  Among  these  are  the  Lavcrania  malarice,  the  Leish- 
mania  donovani,  Balantidium  coli,  Balantidium  minutum,  Nycto- 
tJierus  faba,  and  a  number  of  others. '  Of  these  the  most 
important  is  that  caused  by  the  Balantidium  coli. 

BALANTIDIC    DYSENTERY. 

Balantidic  dysentery  is  an  acute  inflammatory  afl^ection  of 
the  large  intestine  which  may  result  in  acute  or  chronic  ulcers, 
caused  by  the  Balantidium  coli  (Malmsten). 

It  is  quite  likely  that  these  parasites  were  originally  dis- 
covered by  Leeuwenhoek,  but  Malmsten  gave  the  first  satis- 
factory description  of  them.  Since  then  balantidial  dysentery 
has  been  frequently  recorded  in  medical  literature,  and  the 
disease  probably  exists  to  a  much  greater  degree  in  many 
countries  than  the  literature  would  seem  to  indicate. 

Cases  occur  frequently  in  the  Philippine  Islands,  Japan 
and  Europe,  and  isolated  cases  have  been  found  in  nearly  all 
tropical  countries  in  the  Eastern  Hemisphere  in  which  a 
search  has  been  made  for  the  parasite  by  competent  labora- 
tory workers. 


BALANTIDIC    DYSENTERY.  305 

The  disease  is  due  to  the  Balantidimn  coli,  but  the  method 
of  transmission  has  not  been  satisfactorily  demonstrated.  A 
series  of  experiments  made  some  years  ago  by  workers  in  the 
Bureau  of  Science  at  Manila  showed  that  cholera,  typhoid, 
Ameha  histolytica,  Balantidiiim  coli,  and  other  micro-organisms 
fed  to  healthy  pigs  were  not  recoverable  from  the  stools,  with  the 
single  exception  of  the  Balantidiiim  coli.  It  is  assumed  that 
one  of  the  principal  factors  in  the  transmission  of  this  disease 
is  due  to  soil  pollution.  Pigs  probably  become  infected  by 
consuming  the  stools  of  people  that  are  afflicted  with  the 
disease. 

The  exact  method  of  infection  is  unknown,  but  it  probably 
differs  very  little  from  that  of  amebic  dysentery. 

The  intestines  often  contain  a  diphtheroid  membrane. 
Ulcers  are  generally  found  in  the  rectum  and  colon.  The 
Balantidium  coli  can  usually  be  found  in  the  bowel  contents 
and  by  scraping  the  mucosa  of  the  infiltrated  areas. 

The  disease  usually  attracts  attention  through  attacks  of 
severe  diarrhea  which  alternate  with  constipation ;  there  is 
also  considerable  disturbance  of  the  digestion,  and  usually 
vomiting  with  loss  of  appetite  occurs.  Mucus  is  often  found 
in  the  stools,  but  it  is  rare  to  find  blood.  Sometimes  there  is 
edema  of  the  face  and  legs,  and  death  may  take  place  from 
exhaustion.  The  fever  is  usually  higher  than  in  amebic 
dysentery,  especially  during  the  period  of  acute  diarrhea. 

Sometimes  the  parasites  cause  cysts  in  the  liver.  The  dis- 
ease is  usually  associated  with  amebse,  uncinaria  and  other 
common  intestinal  parasites. 

TREATMENT. 

There  is  no  specific  treatment  for  the  ordinary  type  of 
dysentery,  and  reliance  must  be  placed  upon  rest  in  bed, 
liquid  diet  and  active  purgation  with  sodium  sulphate.  Rectal 
irrigations  with  quinin  are  often  useful. 

The  same  rules  applicable  to  the  prevention  of  amebic 
dysentery  are  also  effective  in  guarding  against  balantidic 
dysentery. 


20 


306  TROPICAL   DISEASES. 

AMEBIC    DYSENTERY. 

The  use  of  the  term  amebic  dysentery  is  now  commonly 
restricted  to  an  acute  or  chronic  disease  of  the  intestines, 
caused  by  the  Ameba  histolytica  (Schaudinn),  and  exciting  an 
enteritis  terminating  in  characteristic  ulcer  formation.  A 
frequent  sequela  is  abscess  of  the  liver  and  sometimes  other 
parts  of  the  body.  It  is  known  variously  as  amebiasis,  amebic 
enteritis,  amebic  colitis  and  loschiasis. 

As  early  as  1860  Lamb'^i  observed  amebse  in  the  stools  of 
a  child  suffering  from  diarrhea.  In  1870  Luis'^^  found  similar 
organisms  in  cholera  patients,  and  in  1875  Losch'''^  described 
amebse  which  he  recovered  from  the  stools  of  a  man  suffering 
with  chronic  diarrhea.  His  drawings  indicate  that  he  was 
dealing  with  the  tetragena.  His  observations  were  consider- 
ably obscured  by  the  fact  that  later  Grassi,'^'*  Cunningham'''^ 
and  Luis'^6  found  that  the  stools  of  healthy  persons  in  the 
tropics  frequently  contained  amebse.  Koch,''"^  in  1893,  found 
amebse  in  ulcers  of  cases  of  dysentery  in  Egypt.  Later  Kar- 
tulis'^^  began  a  series  of  investigations,  and  finally  concluded 
that  endemic  dysentery  was  due  to  amebse  and  epidemic 
dysentery  was  due  to  bacteria.  Soon  afterward  a  discussion 
began,  which  has  not  yet  been  finally  settled,  as  to  whether 
amebse  are  always  pathogenic  or  whether  they  are  only  patho- 
genic under  certain  circumstances,  and  as  to  the  question  of 
different  kinds  of  amebse.  Schaudinn"^  insisted  that  the  Ameba 
histolytica  was  the  true  cause  of  amebic  dysentery,  and  other 
workers  gave  partial  confirmation  of  Schaudinn's  work.  In 
1913  Walker,^o  ^^o  made  an  extensive  study  of  the  disease 
in  the  Philippines  over  a  period  of  several  years,  finally  pub- 
lished a  complete  report  in  the  Journal  of  the  Bureau  of 
Science.  In  this  report  practically  all  of  the  previous  work 
was  carefully  reviewed,  and  most  convincing  evidence  was 
adduced  that  there  are  pathogenic  and  non-pathogenic  amebse, 
but  the  histolytica  was  probably  the  ameba  responsible  for 
practically  all  cases  of  dysentery,  and  that  the  so-called  ordi- 
nary water  ameba  could  frequently  be  found  in  the  stools  of 
persons  over  period  of  years  without  the  appearance  of  any 
symptoms;  also,  it  was  regarded  as  not  likely  that  ordinary 
water  ameba  or  other  harmless  types,  by  symbiosis  or  other 


Amebic  dysentery.  307 

manner,  could  be  transformed  into  a  histolytica  or  other  path- 
ogenic ameba.  He  also  showed  that  the  tetragena  is,  in  all 
probability,  the  same  organism  as  the  histolytica.  Other 
workers  throughout  the  world  have  practically  come  to  the 
same  conclusion.  For  instance,  in  Panama,  in  the  installa- 
tion of  water  supplies,  the  presence  of  the  ordinary  water 
ameba  was  disregarded,  without  any  apparent  deleterious 
results  following  therefrom.  Walker  also  showed  that  patho- 
genic amebse  were,  in  all  probability,  not  conveyed  by  water 
supplies  in  the  ordinary  sense. 

Amebic  dysentery  is  found  very  generally  throughout  the 
tropical  world,  but  there  are  many  large  islands  and  other 
extensive  areas  with  large  populations  in  this  belt  in  which 
the  disease  does  not  occur.  It  is  frequently  found  in  the 
Southern  part  of  the  United  States,  and  recently  cases  have 
been  found  in  New  York  City,  the  origin  of  which  it  is  diffi- 
cult to  trace  to  outside  sources.  In  the  Tonga  Islands,  for 
instance,  amebic  dysentery  is  confined  entirely  to  new  arrivals 
who  bring  the  disease  with  them.  It  is  not  known  to  exist  in 
New  Zealand,  and  no  cases  have  been  reported  from  the 
northern  territory  of  Australia.  It  prevails  extensively  in 
Java,  Malay  Peninsula,  Siam,  Borneo,  Sumatra,  Philippines, 
China,  Japan,  Ceylon,  and  in  many  parts  of  India,  Egypt  and 
tropical  Africa.  It  is  said  to  be  rare  in  Central  America  and 
the  West  Indies,  but  common  in  Brazil  and  Chili.  In  Europe 
it  is  known  to  occur  in  Russia  and  Germany,  and,  quite  fre- 
quently, in  Italy.  The  disease  is  often  endemic,  but  never 
spreads  in  epidemic  form. 

In  view  of  the  recent  work  by  W^alker,  in  confirmation  of 
that  of  Schaudinn  and  others,  it  may  be  said  that  amebic 
dysentery  is  caused  by  the  Ameba  histolytica.  Although  there 
are  a  great  many  kinds  of  amebee,  only  a  few  are  parasitic. 
The  principal  interest,  in  so  far  as  man  is  concerned,  is  cen- 
tered in  the  genus  Entamcha,  which,  among  many  others, 
contained  the  E.  coli  and  the  E.  histolytica.  The  E.  coli  is 
frequently  present  in  the  intestines  of  healthy  people.  The 
E.  histolytica  is  probably  pathogenic,  and  may  be  distinguished 
by  these  data:  It  averages  30  microns  in  diameter,  is  grayish 
and  dull-looking,  without  clearly  defined  ectoplasin,  and  pos- 
sesses a  large  nucleus.    Its  movements  are  sluggish,  and  when 


308  TROPICAL   DISEASES. 

it  becomes  encapsulated  it  divides  into  ei^ht  young  entamebse. 
The  Eiitanieba  histolytica  is  a  distinct  parasite  in  the  intestines 
oi  man,  and  produces  there  and  in  other  organs  most  intense 
destructive  changes.  It  is  recognizable  by  its  larger  size  (20 
to  60  microns),  and  by  the  striking  contrast  between  its  gran- 
ular cytoplasm  and  its  glassy,  refractive,  colorless  ectoplasm; 
the  latter  is  usually  in  active  motion,  throwing  out  and  re- 
tracting pseudopods  into  which  the  remainder  of  the  body 
streams.  It  multiplies  also  by  fission,  and  when  it  undergoes 
encapsulation  divides  into  four  new  amebse.  The  Entameba 
tctragena  is  identical  with  this  (McCullum). 

It  is  not  likely  that  the  common  source  of  infection  is 
through  drinking-water  or  by  vegetables  contaminated  by 
feces  during  the  time  they  were  grown.  It  is  more  likely  that 
the  disease  is  spread  by  those  ill  with  the  disease  and  by 
carriers.  The  stool  habits  of  Oriental  peoples,  who  wash  the 
anus  with  the  fingers  moistened  with  water  which  is  often 
kept  in  a  bowl  in  the  toilet  and  seldom  changed,  make  it 
more  than  likely  that  persons  who  handle  food  and  water 
which  are  soon  served  at  the  table  may  become  infected. 
From  a  practical  standpoint,  however,  the  prophylaxis  which 
has  been  recommended  for  many  years  to  boil  all  drinking- 
water  and  abstain  from  the  use  of  fresh  vegetables  in  a  raw 
state  brought  about  the  desired  result, /although  the  infection 
arose  from  another  source.  It  is  quite  evident  that  if  vege- 
tables, after  having  been  handled  by  the  fingers  of  infected 
servants,  are  brought  to  the  table  without  being  cooked  the 
disease  might  be  readily  transmitted  in  this  way,  and  also 
that  if  servants  contaminate  the  drinking-water  shortly  before 
it  is  served  this  is  another  means  of  conveying  the  infection. 
It  has  been  fairly  well  shown  that,  in  the  ordinary  environ- 
ment outside  of  the  human  intestine,  it  is  rare  for  the  his- 
tolytica to  remain  alive  for  more  than  several  hours. 

The  amebse,  after  entering  the  large  intestinal  tract,  prob- 
ably reproduce.  The  young  amebse  penetrate  the  mucosa, 
probably  by  passing  between  the  cells  of  Lieberkuhn's  folli- 
cles, and  then  enter  the  lymphatics  and  make  their  way  to  the 
muscular  coat  and  the  deeper  structures  of  the  gut,  where 
they  live  and  feed  from  the  tissue-cells,  and,  perhaps,  the  cells 
of  the  blood.    Often  they  enter  the  radicles  of  the  portal  vein, 


AMEBIC    DYSENTERY.  309 

and  sometimes  the  mesenteric  arteries,  in  which  event  they 
may  cause  thrombosis.  Those  in  the  portal  vein  may  be 
carried  to  the  Hver  and  produce  abscesses.  In  the  submucosa 
of  the  intestines  they  cause  infiltrations  resulting  in  the  for- 
mation of  ulcers,  which  become  infected  with  bacteria  and 
produce  the  characteristic  ulcers  with  undermined  edges,  and 
with  their  long  axes  usually  transverse  to  the  direction  of  the 
gut.  Occasionally  an  ulcer  perforates  and  peritonitis  results. 
Amebic  dysentery  may  persist  for  years,  and  it  not  infre- 
quently happens  that  large  ulcers  are  found  at  autopsy  in  per- 
sons dead  from  other  causes  and  free  from  symptoms  of 
dysentery  during  life.  When  the  ulcers  are  very  numerous, 
whole  sections  of  the  gut  may  in  consequence  become  gan- 
grenous. Sometimes,  after  cicatrization  takes  place,  contrac- 
tions occur  which  result  in  stenosis,  and,  perhaps,  in  obstinate 
constipation.  The  cicatrized  ulcers  often  become  pigmented 
through  the  interaction  of  sulphurated  hydrogen  and  blood 
iron. 

As  a  rule^  the  cadavers  of  subjects  dead  of  amebic  dysen- 
tery are  emaciated,  and  the  abdomen  is  sunken ;  the  rigor 
mortis  begins  early,  is  not  well  marked,  and  soon  passes  off, 
and  decomposition  begins  quickly.  On  opening  the  abdomen 
the  coils  of  the  small  intestine  are  usually  found  to  be  normal 
in  appearance,  but  at  times  they  are  congested.  The  large 
intestine  is  generally  contracted,  thickened,  and  may  be  gan- 
grenous in  sections,  or  even  throughout  its  entire  length,  The 
mesocolic  glands  are  usually  enlarged  and  hyperemic.  Com- 
monly the  colon  is  adherent  to  the  liver,  spleen,  or  other 
neighboring  structures.  On  opening  the  colon  the  mucosa 
will  be  found  red  and  inflamed,  with  numerous  areas  of  ulcera- 
tion and  infiltration.  These  areas  are  most  commonly  found 
in  the  cecum,  the  hepatic  flexure  and  the  sigmoid  colon,  but 
ulcers  also  occur  in  other  parts  of  the  large  intestine.  Deeper 
circular  or  oval  ulcers  may  be  noted  with  their  surfaces  cov- 
ered with  the  dark-reddish  sloughs,  their  edges  undermined, 
and  their  bases  formed  by  the  muscular  coats.  Oval  ulcers 
have  their  long  diameters  transverse  to  the  bowel,  in  the 
majority  of  instances.  Scrapings  from  these  ulcers  show 
blood-cells,  leucocytes,  bacteria  and  anieba.  The  Pever 
patches   may   be   enlarged,   and   the   lower   end   of   the   small 


310  TROPICAL   DISEASES. 

intestine  may  show  bright-reddish  nodules.  Frequently  an 
ulcer  is  found  in  the  vermiform  appendix. 

The  liver  is  frequently  fatty,  congested,  and  may  be  the 
seat  of  one  or  more  abscesses,  which  vary  in  size  from  that 
of  a  pea  to  that  of  an  orange,  or  even  larger.  Frequently 
scar-tissue,  the  result  of  former  abscesses,  is  found  in  the 
liver.  The  pancreas  is  usually  normal  and  the  spleen  is  not 
enlarged,  but  at  times  may  contain  an  abscess.  Ordinarily, 
the  kidneys  show  a  parenchymatous  inflammation.  The  con- 
tents of  the  thoracic  cavity  are  usually  normal,  although  at 
times  there  may  be  a  hepatopulmonary  abscess. 

The  onset  of  the  disease  is  not  always  sudden,  and  at 
times  may  be  very  insidious.  The  patient  may  have  merely 
the  feeling  of  an  indefinite  illness,  but,  as  a  rule,  in  the  acute 
type  the  onset  is  abrupt,  and  is  preceded  by  slight  diarrhea, 
which  alternates  with  constipation ;  often  diarrhea  is  not 
present.  The  stools,  which  may  reach  thirty  per  day,  con- 
tain blood  and  mucus,  and  occasionally  greenish  matter.  On 
microscopic  examination  the  bowel  contents  show  mucus, 
amebse,  bacteria,  and  frequently  shreds  of  tissue.  There  is 
usually  loss  of  appetite,  and  there  may  be  nausea  and  vomit- 
ing, with  great  derangement  of  the  digestion ;  the  abdomen  is 
retracted,  and  usually  painful  upon  pressure  over  the  area  of 
the  large  bowel.  Microscopic  examination  of  the  blood  often 
shows  a  reduction  in  the  number  of  erythrocytes,  and  there 
may  be  a  leucocytosis  of  20,000  or  more  per  cubic  millimeter. 
Billet  states  that  the  number  of  eosinophiles  is  increased 
even  in  the  absence  of  hookworm  or  other  helminths.  The 
urine  is  diminished  in  quantity,  and  may  contain  albumin  and 
casts.  In  the  white  race  the  skin  often  takes  on  a  peculiar 
pallor.  There  may  be  fever  of  remittent  type,  but  it  seldom 
rises  to  more  than  38.5°  C.  (101°  F.).  With  the  fall  of  tem- 
perature there  is  usually  a  decrease  in  the  pain  and  tender- 
ness in  the  abdomen.  This  may  be  a  favorable  sign,  termi- 
nating in  recovery,  or  it  may  indicate  either  a  gangrenous 
complication  or  hemorrhage.  If  recovery  takes  place,  the 
stools  become  less  frequent,  and  are  gradually  formed,  and  free 
of  blood  and  mucus.  In  fatal  cases  death  often  takes  place 
during  the  first  week  or  ten  days  from  the  onset  of  the  acute 
symptoms.     In  the  chronic  type  of  the  disease  death  often 


AMEBIC    DYSENTERY.  311 

takes  place  quite  unexpectedly.  Persons  who  are  apparently 
in  fair  average  health  apply  for  hospital  treatment,  complain- 
ing of  weakness  and  exhaustion.  They  do  not  give  an}-  his- 
tory of  diarrhea  or  other  symptoms  to  indicate  disease  of  the 
intestines,  and  frequently  die  within  a  few  days  after  admis- 
sion ;  in  such  instances  at  autopsy  several  feet  of  gangrenous 
intestine,  studded  with  typical  amebic  ulcers,  near  the  rec- 
tum, is  a  common  finding.  Others,  subjects  of  the  chronic 
type  of  the  disease  in  question,  may  simply  present  the 
clinical  picture  of  an  intermittent  indigestion,  but  upon  ex- 
amining the  stools  Amebcc  histolytica  are  found. 

Ameha  Carriers.  It  frequently  happens  that  persons  are  car- 
riers of  amebic  dysentery  who  show  no  sign  of  illness,  nor 
benefit  from  specific  treatment.  At  the  present  time  it  is  not 
known  whether  there  may  be  ameba  carriers  with  a  normal 
and  intact  mucosa  of  the  intestinal  tract. 

Sometimes  it  happens  that  subjects  of  amebic  dysentery 
also  contract  the  bacillary  type  of  the  disease,  and  in  these 
cases  there  is  generally  a  higher  fever,  nausea  and  vomiting, 
with  marked  constitutional  disturbance.  The  end  usually 
comes  quickly,  and  the  patient  may  die  in  a  state  of  delirium. 
At  rare  intervals  there  is  perforation,  followed  by  peritonitis. 

The  most  frequent  complication  of  amebic  dysentery  is 
hepatic  abscess;  other  complications,  of  less  frequent  inci- 
dence, being  gangrene  of  the  bowel,  peritonitis  and  excessive 
hemorrhage.  Amebic  abscess  of  the  liver  usually  shows  the 
same  symptoms  as  abscess  of  the  liver  from  other  causes. 
Tenderness  over  the  organ,  with  chills  and  fever,  always 
should  be  regarded  w^ith  suspicion. 

After  a  person  has  apparently  recovered  from  the  amebic 
dysentery  a  hepatic  abscess  may  occur.  Stenoses  of  the 
colon,  due  to  contractions  of  old  ulcers,  are  not  infrequent, 
and  are  often  cause  of  ill  health  for  many  years. 

Positive  diagnosis  by  clinical  means  between  bacillary 
dysentery  and  other  forms  of  diarrhea,  accompanied  by  blood 
and  mucus  in  the  stools,  is  practically  impossible.  Diagnosis 
can  usually  be  made  quickly  by  microscopic  examination  of 
the  stools  and  with  a  view  to  the  demonstration  of  the  Ameha 
histolytica  or  the  tetragena. 


312  TROPICAL   DISEASES. 

It  is  difficult  to  make  a  satisfactory  prognosis  in  cases  of 
amebic  dysentery,  for  the  disease  may  have  existed  for  a 
much  longer  time  than  is  suspected,  and  hepatic  complica- 
tions may  .be  imminent.  In  the  acute  type  Castellani  states 
that  hiccough  is  an  unfavorable  sign,  often  indicating  the 
approach  of  exhaustion  and  death. 

TREATMENT. 

Rest  in  bed  is  usually  of  the  utmost  importance,  and  this 
essential  precaution  is  probably  more  neglected  by  the  patient 
and  the  doctor  than  any  other  feature  of  the  treatment.  Until 
recent  times  many  drugs  have  been  employed,  but  upon  the 
advent  of  the  discovery  of  emetin  in  the  treatment  of  dysen- 
tery by  Rogers^i  other  remedies  have  been  discarded.  The 
patient  should  be  placed  in  bed,  put  on  liquid  diet,  and  given 
a  large  dose  of  castor  oil.  Later  sodium  sulphate  often 
proves  of  value.  After  the  purgative  has  acted,  %  grain  (0.02 
Gm.)  emetin  hydrochlorid  should  be  given  hypodermically ; 
emetin  can  usually  be  purchased  ready  mixed  with  salt  solu- 
tion in  hermetically  sealed  tubes.  Experience  of  the  past  few 
years  shows  that,  while  emetin  is  satisfactory  in  the  majority 
of  cases,  still  there  are  others  in  which  it  appears  to  be  of  no 
value  whatever.  Many  clinicians  believe  that  this  is  due  to 
the  ameba  becoming  encysted,  and,  therefore,  uninfluenced  by 
the  drug  while  in  that  stage.  Some  success  has  been  obtained 
by  waiting  several  weeks  after  the  first  emetin  treatment, 
in  order  to  give  the  encysted  ameba  an  opportunity  to 
develop,  and  thus  reach  the  stage  of  susceptibility  to  the 
effect  of  the  drug.  It  has  also  been  found  that  in  cases  which 
have  resisted  the  ordinary  treatment,  active  purgation  with 
sodium  sulphate,  followed  by  large  doses  of  ipecac,  may  be 
of  value.  Ipecac  is  perhaps  best  g-iven  in  20-grain  (1.3  Gm.) 
doses,  between  8  and  10  p.m.,  with  instruction  to  the  patient 
to  resist,  as  far  as  possible,  the  act  of  vomiting,  which  follows 
the  administration  of  the  drug.  In  using  ipecac  it  is  most 
important  to  select  a  potent  preparation,  and  it  is  generally 
believed  that  powdered  Brazilian  ipecac,  with  an  alkaloidal 
strength  of  2  per  cent.,  gives  the  best  results. 

Some  success  has  also  followed  the  treatment  of  obstinate 
cases  by  the  use  of  salvarsan  in   10-grain   (0.6  Gm.)    doses, 


AMEBIC    DYSENTERY.  313 

repeated  three  times  on  different  days,  if  necessary.  Still 
other  medical  men  have  combined  with  emetin  quinin  irri- 
gations varying  in  strength  from  1  in  5000  to  1  in  750.  About 
3  pints  (1.7  1.)  should  be  injected  slowly  into  an  adult  by 
means  of  a  soft  rectal  tube  2>2  inches  (81.2  cm.)  long,  and 
lubricated  with  carbolated  vaselin  before  insertion.  Some- 
times the  use  of  the  rectal  tube  can  be  greatly  facilitated 
by  the  introduction  into  the  rectum  of  a  1-grain  (0.065 
Gm.)  suppository  of  cocain.  Many  other  substances  have 
been  recommended  for  irrigation,  but  quinin  probably  has 
the  best  record  of  success.  Dr.  Shattuck's  prescription  was 
very  successfully  used  in  Bilibid  prison  in  Manila  before  the 
emetin  treatment  was  discovered,  and  lately  the  use  of  this 
prescription  has  been  resumed  in  obstinate  cases  in  connec- 
tion with  emetin  treatment. 

Shattuck's  recipe  is  as  follows: 

Simaruba   pulvis    3.00  Gm.   (46.5  gr.). 

Benzonaphthol    3.00  Gm.   (46.5  gr.). 

Bismuth   subnitrate    8.00  Gm.    ( 123.4  gr.) . 

Acacia  pulvis  10.00  Gm.    (154.3  gr.). 

Fluidext.   krameria  13.50  mils   (3.6  fS). 

Aqua  mentha  piperit q.  s.  ad  200.00  mils   (6.7  £5)- 

M.  et  ft.  mix. 

Dose:     Tablespoonful   (15  mils)   every  four  hours. 

For  years  it  has  been  admitted  that  the  best  prophylaxis 
against  amebic  dysentery  was  the  use  of  safe  water  and  the 
avoidance  of  eating  low-growing  garden  vegetables  in  a  raw 
state.  Salads  were  looked  upon  with  suspicion.  It  was 
assumed  that  vegetables  were  especially  dangerous,  because 
they  might  have  been  fertilized  or  irrigated  with  solutions  of 
human  excrement  from  persons  afflicted  with  amebic  dysen- 
tery. It  was  also  assumed  that  pathogenic  amebae  lived  for 
long-  periods  of  time  in  many  tropical  drinking-waters.  This 
is  another  example  of  the  practice  producing-  the  result  with- 
out necessarily  being  based  upon  sound  theory.  In  view  of 
the  work  of  Walker^-  it  seems  more  than  likely  that  infec- 
tions with  amebic  dysentery  are  most  commonlv  transmitted 
by  the  means  of  fingers  of  persons  engaged  in  handling  food. 
Reference  has  already  been  made  to  the  Oriental  custom  of 
washing  the  anus  by  means  of  the  fingers  dipped  in  water  con- 


314  TROPICAL   DISEASES. 

tained  in  a  small  bowl  immediately  after  defecation.  (See  page 
308.)  Walker  showed  that  it  is  extremely  unlikely  that  pathogenic 
amebse  in  the  stools  of  infected  persons  used  for  fertilizing 
vegetables,  remain  alive  for  more  than  a  few  days,  and  prob- 
ably only  for  a  few  hours.  Some  of  the  observers  have  held 
that  the  ordinary  amebse  are  found  in  practically  all  surface 
waters  in  the  tropics  and  on  vegetables,  and  may,  under  cer- 
tain environmental  conditions,  become  pathogenic.  If  this  is 
the  true  explanation,  the  origin  of  cases  of  amebic  dysentery 
is  much  simplified.  The  scientific  world,  during  the  past  few 
years,  has  been  inclined  to  disregard  this  view,  and  large 
installations  of  public  water  supplies  and  reservoirs  have  been 
built  without  any  attempt  having  been  made  to  remove  any 
of  the  so-called  pathogenic  amebse.  Water  supplies  with 
amebje  of  this  kind  are  used  in  many  cities  and  districts  with- 
out any  amebic  dysentery  resulting  therefrom.  Studies  made 
during  recent  years  in  Manila  of  the  stools  of  persons  em- 
ployed in  hotels,  restaurants,  and  other  public  places  where 
food  and  drinks  are  served,  have  revealed  a  considerable  per- 
centage of  amebic  dysentery  carriers  among  the  servants ;  and 
in  places  where  cases  of  this  infection  were  occurring  from 
time  to  time,  the  disease  completely  disappeared  after  these 
carriers  were  eliminated. 

BACTERIAL    DYSENTERY. 

There  is  apparently  no  end  to  the  kinds  or  the  variations 
of  the  same  bacteria  that  may  be  responsible  for  dysentery. 
The  Bacillus  dy sentence  is  described  as  having  various  strains 
which  take  the  name  of  the  different  persons  who  have 
described  them,  as,  for  instance,  Kruse,  Shiga,  Flexner, 
Strong,  Hiss,  Castellani,  Wilmore,  and  many  others.  Bacil- 
lary  dysentery  is  found  in  all  parts  of  the  world,  but  it  is 
most  common  in  the  tropics.  It  is  probably  responsible  for 
a  larger  death-rate  in  many  countries  than  cholera  or  any 
other  disease  of  the  intestines.  There  is  frequently  a  heavy 
mortality  from  infection  with  the  dysentery  bacillus  in  the 
summer  among  infants  in  large  cities  of  the  United  States 
and  Europe. 


BACILLARY    DYSENTERY.  315 

BACILLARY    DYSENTERY. 

Bacillary  dysentery  is  an  acute  infection  provocative  of 
enteritis,  and  is  caused  by  one  of  the  various  types  of  the 
dysentery  bacillus.  It  is  characterized  by  diarrhea  accom- 
panied by  pain,  tenesmus,  and  the  passage  of  blood  and 
mucus  in  the  stools. 

With  the  advent  of  the  discovery  of  bacteria  numerous 
observers  reported  different  kinds  of  micro-organisms  as 
being  responsible  for  dysentery  and  other  diarrheal  diseases. 
Probably  no  other  disease  in  the  annals  of  medicine  has  had 
so  many  distinguished  medical  authors  report  t^pon  so  many 
different  bacteria  as  being  definitely  responsible  for  its  origin. 
Contrary  to  many  other  medical  disputes,  the  controversy,  on 
the  w^hole,  has  been  conducted  with  admirable  good  feeling. 
Considerable  light  was  thrown  upon  the  question  between 
1898  and  1900  by  Shiga,^^  ^^i-^q  had  returned  to  Japan  after 
many  years'  study  in  Germany.  Kruse,^'*  at  the  same  period, 
was  making  valuable  contributions  from  Germany.  These 
observers  described  the  cause  of  dysentery  as  a  short  bacillus, 
Gram  negative,  not  clotting  milk,  and  not  producing  gas  in 
sugar  media.  The  question  of  motility  soon  arose,  but 
Kruse's  statement  that  the  bacillus  was  non-motile  proved 
to  be  correct.  Kruse  was  among  the  first  to  call  attention  to 
the  fact  that  there  was  more  than  one  variety  of  the  d}'sen- 
tery  bacillus.  After  him  came  a  long  list  of  observers,  who 
from  dysenteric  stools  isolated  bacilli  which  varied  in  some 
of  the  details  from  those  described  by  Kruse  and  Shiga.^-^ 
Flexner^^  reported  a  dysentery  bacillus  of  moderate  motility 
in  Manila.  Strong'^"  isolated  another  bacillus  in  Manila 
slightly  dift'erent  from  that  of  Flexner.  In  1903  Hiss  and 
Russel^s  described  a  bacillus,  frequently  referred  to  as  the 
F-bacillus,  which  resembled  Flexner's,  but  failed  to  ferment 
saccharose.  In  1904  Castellani^^  isolated  another  bacillus  in 
Ceylon ;  various  observers  in  the  United  States  found  bacilli 
resembling  the  Kruse  type  from  cases  of  diarrhea  in  children. 
In  brief,  the  literature  fairly  teems  with  observations  upon 
bacteria  that  are  supposed  to  be  associated  with  dysentery; 
and,  owing  to  those  discrepancies,  the  whole  question,  from 
the  scientific  standpoint,  is  still  in  a  very  unsatisfactory  state. 


316  TROPICAL    DISEASES. 

Bacillary  dysentery  is  found  in  all  latitudes,  and  should 
be  regarded  as  a  great  tropical  scourge.  In  the  tropics  it  is 
probably  responsible  for  a  greater  number  of  deaths  and  cases 
of  illness  than  any  other  disease.  Cholera  is  frequently  much 
more  spectacular,  but  a  careful  study  of  the  health  conditions 
in  any  tropical  country  will  usually  show  that  bacillary  dysen- 
tery is  responsible  for  a  greater  morbidity  and  mortality. 
The  eating  habits  of  the  people,  especially  Asiatics,  and  the 
temperature  favorable  for  its  spread  are  operative  through- 
out the  whole  year,  premises  that  make  the  disease  a  formid- 
able opponent  of  the  sanitarian.  In  countries  like  New 
Guinea,  Java,  Ceylon,  India,  the  Philippines,  the  victims  of 
dysentery  die  literally  by  the  thousands,  but,  as  the  mortality 
does  not  approach  that  of  cholera,  it  attracts  less  attention. 
The  deaths,  especially  among  children  during  the  summer- 
time in  the  larger  cities  throughout  the  world,  also  is  a  very 
important  factor  in  the  mortality  figure.  It  has  been  noticed 
in  the  Philippines,  for  example,  that  the  disease  will  break 
out  simultaneously  on  many  different  islands,  and  carefiil 
inquiries  made  over  a  period  of  years  have  failed  to  show  any 
connection  between  cases  occurring  on  different  islands, 
although,  after  the  disease  once  makes  its  appearance,  its 
spread  can  frequently  be  traced  from  place  to  place.  Very 
often  the  affection  makes  its  appearance  at  the  head  waters 
of  rivers,  and  spreads  to  the  towns  and  villages  which  lie 
along  their  banks.  It  has  been  frequently  observed  that  the 
spread  of  the  disease  is  intimately  connected  with  the  pres- 
ence of  flies.  Again  and  again  outbreaks  of  bacillary  dysen- 
tery have  been  stopped  when  human  excrement  was  collected 
in  fly-proof  receptacles,  and  measures  taken  to  eliminate  flies 
and  to  prevent  their  gaining  access  to  human  stools.  The 
disease  is  often  associated  with  large  collections  of  people 
among  whom  provision  for  the  safe  disposal  of  human  excre- 
ment is  lacking;  thus,  it  is  frequently  associated  with  armies 
in  time  of  war,  and  with  religious  pilgrimages,  camping  par- 
ties, etc.  Many  observers  also  believe  that  dark,  damp  days 
greatly  favor  the  spread  of  the  disease,  in  that  the  organism 
has  a  longer  life  under  favorable  weather  conditions,  and  thus 
has  many  additional  opportunities  to  find  its  way  to  the  intes- 
tines of  human  beings.     Great  epidemics  of  the  disease  have 


BACILLARY   DYSENTERY.  317 

occurred  in  the  past,  and  spread  over  whole  countries.  Note- 
worthy epidemics  occurred  in  Europe  at  numerous  periods, 
the  last  recorded  being  that  of  1834  to  1836.  Smaller  epi- 
demics occurred  very  frequently  in  institutions  like  orphan 
asylums,  insane  hospitals  and  prisons. 

Bacillary  dysentery  is  usually  ascribed  to  bacteria  which 
belong  or  are  allied  to  the  principal  types.  Type  one  is  the 
Kruse-Shiga4i^6ar?7/u.y  dyscntericu,  and  others  are  sometimes 
described  as  variants.  The  bacilli  are  found  in  the  dejecta, 
and  can  be  recovered  in  scrapings  taken  from  the  surface  of 
the  bowel  postmortem.  The  literature  of  the  various  kinds  of 
bacteria  associated  with  dysentery  is  most  extensive,  but  a 
review  of  it  does  not  seem  to  be  indicated  here.  The  disease 
is  spread  by  the  feces  of  persons  suffering  from  the  infection, 
and  also  by  persons  who  are  merely  its  carriers.  Strong  and 
Musgrave^o  have  reported  a  case  of  infection  in  a  man  to 
whom  they  gave  a  pure  culture  of  the  dysentery  bacillus, 
which  soon  provoked  an  attack  characteristic  of  dysentery. 
The  disease  is  probably  spread  in  the  same  manner  as  typhoid 
fever,  and  can  be  contracted  only  by  conveying  to  the  mouth 
parts  of  stools  which  contained  dysentery  bacilli.  There  are 
many  ways  in  which  this  may  be  brought  about,  although 
absolute  and  definite  proof  covering  any  considerable  numlDer 
of  cases  is  lacking.  The  most  probable  methods  are,  perhaps, 
by  the  fingers  coming  in  contact  with  dysentery  stools  and 
then  infecting  the  food  or  drink  of  other  persons.  Another 
common  method  of  infection  is  by  flies  which  have  access  to 
dysentery  stools,  and  later  contaminate  food  and  drink.  It 
has  been  asserted  that  dried  dysenteric  stools,  which  mav  be 
blown  about  in  the  form  of  dust,  may  be  responsible  for  the 
dissemination  of  the  disease.  It  has  been  demonstrated  many 
times  that  flies  may  have  dysentery  organisms  on  their  feet, 
and  that  even  the  excreta  of  flies,  which  have  fed  on  dysen- 
teric stools,  may  contain  the  bacilli ;  and  in  this  wa}^  transfer 
them  to  food  and  drink.  The  dysentery  bacilli  have  been 
found  in  the  feces  of  monkeys  and  rabbits,  and  it  would 
appear  that  animals  might  be  a  factor  in  the  spread  of  the 
disease.  Many  outbreaks  in  camps,  public  institutions,  and 
even  private  houses,  have  been  traced  to  persons  who  were 
employed  about  the  kitchen  in  preparing  food.    A  theory  also 


318  TROPICAL   DISEASES. 

has  been  advanced  that  the  bacilli  are  capable  of  living  in  the 
alimentary  canal  without  causing  symptoms  until  the  vitality 
of  the  host  is  lowered  by  chill,  indigestion,  or  some  other 
intercurrent  affection.  This  might  explain  the  simultaneous 
appearance  of  the  disease  among  persons  residing  over  large 
areas  of  territory,  and  even  on  different  islands,  and  without 
anv  apparent  communication  between  them,  but  at  best  the 
explanation  is  very  unsatisfactory.  The  dysente;ry  carrier  is 
probably  a  most  important  factor  in  the  spread  of  the  disease. 
Observations  made  during  a  dysenteric  outbreak  have  shown 
that  a  considerable  percentage  of  apparently  healthy  individ- 
uals may  harbor  the  specific  bacilli.  Persons  who  have  at 
some  previous  time  had  an  attack  of  dysentery  are  regarded 
with  great  suspicion,  and  examinations  made  of  their  stools 
many  months  after  the  attack  have  shown  the  presence  of 
the  dysentery  bacillus. 

Dysentery  bacilli  taken  into  the  body  with  food  and  drink 
apparently  do  not  multiply  until  after  they  have  passed  the 
stomach.  They  may  be  found  growing  throughout  the  whole 
length  of  the  intestines,  the  colon  being  principally  involved. 
The  micro-organism  produces  toxins  absorbed  into  the  blood,  of 
which  two  are  known.  One  acts  upon  the  large  intestine,  and 
the  other  on  the  nervous  system.  One  is  excreted  by  the 
large  intestine,  and  causes  the  lesions  which  are  associated 
with  dysentery.  In  the  process  of  excretion  the  tissue  of  the 
muscular  and  mucous  coats  is  destroyed  by  coagulative 
necrosis  and  thrombosis.  This  process  creates  the  diphthe- 
roid membrane  which  is  first  noted  on  the  summits  of  the 
ridges,  and  later  spreads  to  the  space  between  the  ridges. 
Micro-organisms  destroy  this  diphtheroid  membrane,  which 
then  separates  off  in  flakes,  leaving  ulcers  which  are  at  first 
superficial,  but  later  become  deep.  These  ulcers  heal  with 
the  formation  of  scar-tissue.  The  toxin  of  the  disease  may 
attack  the  nervous  system,  and  cause  peripheral  neuritis.  At 
times  the  bacilli  enter  the  blood  and  cause  septicemia. 
Darling^i  has  reported  cultivation  of  the  bacilli  from  the 
blood  of  cases  of  bacterial  dysentery.  Painful  joint  changes, 
causing  effusion  into  the  joints,  are  not  uncommon,  the 
ankles,  knee  and  hip  being  most  frequently  involved;  it  often 
happens  that  when  one  joint  clears  another  becomes  affected. 


BACILLARY    DYSENTERY.  319 

Usually  the  peritoneum  is  normal,  but  the  blood-vessels  of 
the  colon  are  injected,  and  the  mesocolon  may  be  infiltrated 
with  lymph ;  often  there  are  adhesions  of  the  sigmoid  colon 
to  the  omentum,  pelvis,  bladder,  or  small  intestine — in  fact, 
adhesions  are  often  g-eneral.  The  quantity  of  peritoneal  fluid 
is  usually  normal,  and  the  bowels  do  not  have  the  sticky  con- 
dition so  frequently  found  in  cholera.  The  small  intestine 
may  be  hyperemic,  but  this  does  not  differ  from  the  condition 
found  in  many  other  diseases;  at  times  there  are  ecchymotic 
spots  on  the  walls  of  the  gut.  The  large  bowel  may  be  gan- 
grenous along  varying  lengths  of  its  extent,  and  on  opening 
it  the  mucous  surface  is  covered  with  a  coagulated  exudate 
in  the  form  of  a  false  membrane,  the  surrounding  areas  of  the 
mucosa  being  hyperemic  and  edematous.  As  a  rule,  there  are 
many  ulcers  with  clean  surfaces  and  elevated  edges,  and  this 
ulcerative  process  may  be  very  extensive.  Other  spots  of 
ulceration  are  covered  with  sloughs,  which  may  extend  deeply 
into  the  bowel  and  cause  perforation  and  peritonitis.  In  cases 
which  have  died  from  some  other  complaint  the  intestines  are 
often  found  matted  together.  In  the  colon  will  be  found 
many  scars  with  pigmented  deposits  indicating  the  site  of 
former  ulcers,  and  sometimes  scar-tissue  will  have  contracted 
and  reduced  the  lumen  of  the  bowel  to  small  proportions. 
The  cecum  may  contain  polypi,  which  protrude  from  the 
mucous  membrane,  and  this  state  of  affairs  is  ordinarily 
referred  to  as  colitis  polyposa.  In  children  there  is  often  a 
hyperplasia  of  solitary  gland-follicles.  Microscopically,  the 
exudate  at  first  contains  few  cells  and  the  mucosa  is  seen  to 
be  congested ;  later  the  exudate  into  the  submucosa  seems  to 
change  into  fibrin  and  the  vessels  are  dilated,  and  contain 
numerous  polymorphonuclear  leucocytes  extravasated  into 
the  surrounding  tissue. 

Bacillary  dysentery  is  frequently  descril^ed  as  occurring 
in  distinct  types,  but  in  actual  j^ractico  it  is  most  difficult  to 
differentiate  between  them.  The  symptoms  largely  depend 
upon  the  severity  of  the  infection,  and  the  resistance  of  the 
individual.  There  are,  however,  outbreaks  in  which  the  A^ast 
majority  of  the  cases  are  of  an  acute  mild  type  with  a  low 
mortality.  In  some  individuals,  in  whom  cicatricial  changes 
in    the    bowel    have    taken    place,    the    disease    mav    become 


320  TROPICAL   DISEASES. 

chronic,  and  last  over  a  long  period.  In  fact,  some  subjects 
suffer  from  chronic  dysenteries  or  its  effects  for  years  after 
the  acute  symptoms  have  subsided.  During  some  outbreaks 
the  gangrenous  type  predominates.  Again,  there  are  out- 
breaks in  which  children  are  mostly  affected. 

In  acute  dysentery  the  incubation  period  varies  from  one 
to  three  days.  It  usually  begins  with  loss  of  appetite  and 
malaise,  followed  by  pain  in  the  lower  abdomen,  and  an 
urgent  desire  to  defecate.  The  first  movements  are  usually 
formed  stools,  and  some  relief  is  obtained  afterward,  but  this 
is  usually  followed  by  another  attack  of  pain,  and  the  stools 
become  more  and  more  liquid,  until  finally  blood,  flakes  and 
mucus  is  passed.  At  the  height  of  the  outbreak,  practically 
only  blood  and  mucus  are  passed.  The  lower  bowel  becomes 
raw  and  the  anus  inflamed  and  painful,  and  prolapse  of  the 
bowel  may  occur.  The  urine  becomes  scanty  in  amount,  caus- 
ing an  apparent  increase  in  the  quantity  of  urea.  In  mild  cases 
there  is  a  bowel  movement  about  once  an  hour,  but  in  severe 
cases  there  may  be  fifty  or  more  during  twenty-four  hours. 
The  constant  defecation  prevents  sleep  and  rest,  and  the 
patient  becomes  greatly  exhausted  from  physical  exertion 
alone,  which,  added  to  the  toxemia  produced  by  the  disease, 
weakens  the  patient  very  rapidly.  In  spite  of  the  constant 
diarrhea,  there  is  no  great  thirst,  and  this  craving  is  usually 
satisfied  by  small  quantities  of  water.  Nausea  frequently 
occurs,  and  there  is  striking  anorexia  with  digestive  disturb- 
ances. The  whole  abdomen  becomes  painful  and  sore,  and, 
in  untreated  cases,  vomiting  is  frequent.  It  often  happens 
that  formed  feces  accumulate  in  the  upper  part  of  the  intes- 
tines, which  are  not  affected  by  the  disease.  Typical  dysen- 
teric stools  are  composed  of  blood  and  mucus  only,  but  in 
more  serious  cases  there  are  numerous  white  shreds  as  well. 
Microscopically,  numerous  bacteria  can  be  seen,  leucocytes, 
erythrocytes  and  epithelial  debris.  The  temperature  ranges 
from  38.6°  to  39.5°  C.  (101°  to  103°  F.).  The  pulse  is  acceler- 
ated, and  in  serious  cases  it  may  be  irregular.  No  marked 
changes  occur  in  the  blood,,  although  there  may  be  an  increase 
of  the  polymorphonuclear  leucocytes.  The  lungs  are  normal 
and  delirium  is  unusual.  In  serious  cases  the  foregoing-  symp- 
toms increase  in  severity ;  the  temperature  drops  suddenly  to 


BACILLARY    DYSENTERY.  321 

normal;  the  motions  decrease  in  number;  hiccough  appears, 
and,  after  a  stage  of  exhaustion,  death  occurs,  commonly  dur- 
ing the  second  or  third  week  of  the  illness.  If  the  patient  is 
to  recover,  the  symptoms  gradually  improve,  blood  and  mucus 
disappear  from  the  stools,  the  tongue  becomes  clean,  and  con- 
valescence usually  begins  about  the  end  of  one  week.  In 
severe  cases  convalescence  may  be  prolonged  for  as  long  as 
a  month. 

Gangrenous  Dysentery.  This  type  of  the  disease,  as  a 
rule,  begins  very  insidiously,  and  may  not  attract  attention 
until  a  few  hours  before  death.  The  patient  suddenly  col- 
lapses, and  dies  within  a  few  hours.  The  typical  dysenteric 
stools  are  not  present  in  this  form  of  the  disease,  but  in  most 
cases  the  onset  occurs  during  an  attack  of  acute  dysentery, 
all  of  the  symptoms  of  which  become  greatly  aggravated,  and 
the  stools  become  very  offensive  and  contain  gangrenous 
sloughs,  which  are  composed  of  the  lining  membrane  of  the 
intestines.  At  times  these  sloughs  are  sufficiently  large  as  to 
appear  in  the  form  of  cylindrical  casts  of  the  intestine.  Re- 
covery from  this  form  of  dysentery  is  extremely  rare. 

Enterodysentery.  This  form  usually  begins  with  chills, 
and  the  temperature  rises  to  about  103°  F.  (39.5°  C),  tend- 
ing to  assume  the  continuous  type ;  the  tongue  is  dry ;  the 
mouth  is  covered  with  sordes;  the  breath  fetid,  and  there  is 
headache,  with  pains  in  various  parts  of  the  body,  and  often 
ecchymoses  under  the  skin.  The  patient  is  usually  stupid 
and  at  times  delirious ;  later  abscesses  frequently  appear, 
especially  in  the  parotid  or  the  ischiorectal  fossae.  Carbun- 
cles, bed-sores,  and  peritonitis  also  frequently  occur.  Death 
usually  takes  place  before  the  end  of  the  first  week. 

Chronic  Bacterial  Dysentery,  This  type  of  the  disease 
usually  follows  the  subsidence  of  an  attack  of  the  acute  form 
from  which  the  patient  apparently  has  recovered.  There  are 
usually  five  or  six  daily  bowel  movements,  which  are  evil- 
smelling,  and  sometimes  contain  blood  and  mucus.  Blood, 
however,  is  often  frequently  absent.  This  is  followed  by 
alternate  periods  of  diarrhea  and  constipation.  The  tongue  is 
unusually  red  and  clean.  Digestion  is  impaired,  and  fermen- 
tative changes  are  frequent.     Profuse  night-sweats  are  com- 

21 


322  TROPICAL   DISEASES. 

mon.  Recovery  often  takes  place  spontaneously.  Patients 
frequently  die  of  some  intercurrent  disease. 

Infantile  Diarrhea.  This  is  an  extremely  common  disease 
among  infants  in  the  tropics,  and  in  nearly  all  respects  is 
similar  to  the  dysentery  or  diarrhea  outbreaks  which  occur 
during  the  hot  months  in  American  cities.  There  is  consider- 
able difference  of  opinion  as  to  whether  the  Flexner  or  the 
Kruse-Shiga  type  of  bacillus  predominates.  The  symptoms 
are  similar  to  those  described  under  Acute  Dysentery.  The 
onset  of  the  disease  is  usually  ushered  in  with  vomiting  and 
a  rise  of  temperature  from  103°  to  104°  F.  (39.5°  to  40°  C), 
the  tongue  is  coated,  the  abdomen  extended  and  tender,  and 
at  first  the  stools  are  green  in  color,  but  later  they  are  mixed 
with  blood  and  mucus.  The  fever  is  often  of  the  remittent 
type.  Death  may  not  occur  for  a  number  of  weeks.  The 
child  usually  wastes,  and  often  after  repeated  attacks  of  diar- 
rhea it  finally  succumbs  to  exhaustion.  In  more  favorable 
cases  it  often  requires  months  to  recover  from  the  attack. 

Bacillary  dysentery  must  be  carefully  distinguished  from 
amebic  dysentery,  and  the  other  many  forms  of  diarrhea 
which  are  so  common  in  the  tropics.  The  typical  bloody 
stools,  the  absence  of  the  Ameba  histolytica,  and  the  presence 
of  one  of  the  dysentery  type  of  bacilli  usually  make  the  diag- 
nosis reasonably  easy.  As  a  rule,  the  disease  also  occurs  in 
epidemic  form,  and  it  is  more  prone  to  be  widespread  than 
limited  to  a  few  cases.  Care  must,  of  course,  be  exercised  to 
exclude  the  presence  of  blood  in  the  stools  from  hemorrhoids, 
cancer,  syphilis,  or  similar  cause. 

Peripheral  neuritis  occurs  as  a  complication  in  a  fair  per- 
centage of  cases.  Peritonitis  is  not  uncommon,  as  well  as 
inflammation  of  the  tendon  sheaths.  In  gangrenous  dysen- 
tery hemorrhage  may  be  a  serious  complication.  Typhoid 
fever  and  dysentery  may  occur  in  the  same  time,  and  cases 
of  appendicitis  have  often  been  known  to  occur. 

Probably  the  most  serious  complication  is  the  stenosis  due 
to  scars  of  the  intestine  left  by  the  healing  of  the  ulcerated 
surfaces.  The  most  constant  sequela  is  probably  constipa- 
tion, with  the  train  of  symptoms  which  follow  in  its  wake. 

A  fair  average  mortality  for  dysentery  is  probably  15  per 
cent.      The    site    of    the    disease    is    an    important    factor;    if 


BACILLARY   DYSENTERY.  323 

located  low  down  in  the  bowel,  the  prognosis  is  much  better 
than  when  situated  higher  up.  Apparently  persons  who  have 
had  the  disease  before,  or  who  have  resided  for  many  years 
in  places  where  the  disease  prevails,  are  less  susceptible 
to  an  attack,  and  do  not  suffer  as  severely  as  newcomers.  It 
has  recently  been  observed  in  a  jail  at  Borneo  that  prisoners 
from  the  lowlands  show  a  much  lower  infection  rate  in  the 
jail  than  prisoners  from  mountain  districts.  It  is  very  well 
recognized  in  Borneo  that  dysentery  prevails  very  extensively 
in  lowlands,  and  only  seldom  in  high  elevations. 

TREATMENT. 
Much  has  been  written  upon  the  treatment  of  bacillary 
dysentery,  and  many  remedies  are  suggested,  but  a  review  of 
the  field  shows  there  is  no  great  difference  between  the 
results,  regardless  of  the  remedy  employed.  This  warrants 
the  inference  that  the  disease  is  not  much  influenced  by  the 
various  methods  of  therapy  which  have  been  advocated. 
Probably  as  good  results  as  any  are  obtained  by  rest  in  bed, 
liquid  diet  without  milk,  and  such  symptomatic  treatment  as 
may  be  necessary  in  order  to  make  the  patient  comfortable. 
It  is  well  to  begin  the  treatment  with  a  suitable  dose  of  castor 
oil;  this  is  to  be  followed  with  5  grains  (0.325  Gm.)  of  bis- 
muth salicylate  and  5  grains  (0.325  Gm.)  of  salol,  made  up 
in  cachets  and  administered  every  two  to  four  hours.  The 
frequency  of  the  dose  should  be  reduced  as  the  stools  become 
less.  Large  enemata  of  warm  normal  salt  solution,  of  borax, 
or  of  bicarbonate  of  soda  in  the  strength  of  5  grains  (0.325 
Gm.)  to  the  ounce  (30  mils),  often  give  much  relief.  This 
should  be  given  with  a  long  rectal  tube,  well  lubricated 
before  it  is  introduced.  If  pain  and  discomfort  continue,  it 
should  be  controlled  with  hypodermic  injections  of  morphin. 
In  spite  of  the  many  favorable  reports  which  have  been  made 
upon  the  use  of  the  dififerent  serums,  the  fact  remains  that 
some  thousands  of  cases  treated  without  serum  show  no  great 
difference  in  results.  If  serum  is  to  be  used,  it  is  better  to 
use  one  of  the  polyvalent  preparations.  Astringent  drugs 
like  tannin  and  bismuth  subnitrate  are  often  found  useful  in 
relieving  the  symptoms.  Collapse  should  be  conil)ated  by 
hypodermic  or  intravenous  injections  of  normal  salt  solution. 


324  TROPICAL   DISEASES. 

The  use  of  calomel,  after  the  administration  of  the  castor  oil, 
is  a  favorite  with  many  doctors,  and  Yi  grain  (0.03  Gm.)  of 
mercury  salt  is  given  hourly  until  twelve  doses  have  been 
taken ;  this  regimen  is  usually  repeated  for  three  days.  The 
saline  treatment  is  another  favorite.  Castellani^^  recommends 
the  following- :  Two  drams  each  (7.80  Gms.)  of  magnesium 
sulphate  and  of  sodium  sulphate,  dissolved  in  an  ounce  (30 
mils)  of  water,  should  be  administered,  and  then  1  dram 
(3.75  mils)  of  each  is  given  hourly,  or  every  two  hours,  until 
the  motions  become  feculent,  and  then  every  three  or  four 
hours  for  another  day.  The  sour-milk  treatment  is  advo- 
cated by  many,  especially  for  subacute  and  chronic  cases.  In 
chronic  cases  the  constipation  is,  perhaps,  best  relieved  by 
liquid  paraffin,  but  if  there  is  actual  constriction,  the  neces- 
sary surgical  cure  should  be  immediately  sought. 

Success  in  the  prophylaxis  of  dysentery  consists  of  pre- 
venting the  stools  of  the  persons  who  have  or  have  had  the 
disease,  or  of  carriers  reaching  the  intestinal  tracts  of  non- 
infected  persons.  The  following  rules  to  prevent  this  have 
long  been  issued  by  the  Health  Department  of  the  Philip- 
pines, and  have  been  found  to  be  very  effective  in  practice. 

These  diseases  can  be  introduced  into  the  system  only 
through  the  mouth.  They  are  caused  by  organisms  too- 
minute  to  be  seen,  except  with  a  microscope,  but  which  may 
be  readily  killed  by  heat,  as  well  as  by  disinfectants,  thus 
making  it  possible  to  combat  such  diseases  successfully  by 
the  use  of  fire  and  boiling  water  when  there  are  no  chemical 
disinfectants  available. 

The  following-  precautions  should  be  taken  at  all  times : 

1.  Use  only  boiled,  distilled,  or  bottled  water,  or  water 
from  an  approved  artesian  well,  for  drinking  purposes  or  for 
cleansing  the  teeth  and  mouth. 

2.  Always  wash  the  hands  thoroughly  after  coming  from 
stool  and  before  eating,  and  see  that  the  servants  do  the  same. 
In  times  of  epidemics  the  use  of  a  1  per  cent,  solution  of 
tincture  of  iodin  or  a  1 :  2000  bichlorid  solution  for  sub- 
merging the  hands  after  washing  them  affords  additional 
safety. 

3.  Do  not  touch  water  or  food  with  the  hands  unless  they 
have  just  been  washed,  well  dried,  and  disinfected  when  prac- 


RAT-BITE   FEVER.  325 

ticable.  These  precautions  must  be  enforced  on  the  servants, 
since  it  is  often  by  their  carelessness  that  such  diseases  are 
spread. 

4.  All  food  should  be  cooked.  Fruit  that  grows  on  trees 
well  above  the  ground  may  be  safely  eaten,  unless  it  has 
been  contaminated  by  handling. 

5.  Flies  may  carry  the  organisms  of  dysentery,  cholera 
and  typhoid  on  their  feet;  therefore,  as  a  protection  against 
contamination  from  this  source,  all  food  should  be  covered 
as  soon  as  it  is  cooked. 

6.  All  manure  and  garbage  should  be  kept  in  covered 
receptacles,  and  properly  disposed  of  to  prevent  the  breeding 
of  flies. 

7.  Boil  all  water  used  for  diluting  milk. 

8.  Keep  kitchen  and  table  dishes  thoroughly  clean,  and 
scald  the  dishes  each  time  before  they  are  used. 

9.  Vegetables  and  fruit  which  grow  on  or  near  the  ground 
should  not  be  eaten  unless  cooked.  Raw  vegetables  are  dan- 
gerous. 

10.  No  diarrhea  or  disorder  of  the  bowels,  however  slight, 
should  go  untreated. 

11.  The  bowels  and  other  eliminating  organs  of  the  bodv 
should  be  kept  in  good  condition. 

12.  The  dejecta  of  dysentery  patients,  as  well  as  that  from 
typhoid  and  cholera  patients,  should  be  thoroughly  disin- 
fected by  adding  to  them  two  or  three  times  their  bulk  of 
5  per  cent,  carbolic  acid,  a  1 :  1000  solution  of  formaldehyd, 
a  5  per  cent,  solution  of  creolin,  a  1 :  500  solution  of  larvacide, 
or  by  burning  or  boiling  them.  The  disinfectant  and  the 
stools  should  remain  in  contact  for  at  least  one-half  hour,  and 
then  they  may  be  disposed  of  in  the  closet,  or  by  burying  and 
covering  with  earth. 

RAT-BITE    FEVER. 

Rat-bite  fever  is  an  infectious  disease  following  tiie  l:)ite 
of  a  rat,  and  includes  similar  fevers  which  at  rare  intervals 
are  consequent  to  bites  of  weasels,  ferrets  and  cats. 

Rat-bite  fever  is  referred  to  frequently  in  ancient  Japanese 
books.     One   of  the   first   fairly   complete    reports   is   that  of 


326  TROPICAL   DISEASES. 

Miyake  made  in  1899,  when  he  reported  11  cases.'^^  Other 
cases  have  since  been  recorded  by  Horder  in  England,*^^  by 
Proescher,  Blake,  and  Tileston,^^  in  the  United  States.  Re- 
cently many  cases  have  been  reported  from  India,  and  the 
disease  has  been  under  investigation  in  that  country  for  some 
time. 

The  religious  belief  of  many  of  the  Indians,  which  pre- 
vents them  from  killing  animals  of  all  kinds,  has  resulted  in 
an  enormous  rat  population.  As  rats  are  not  nearly  so  shy 
in  India  as  in  other  countries,  consequently  they  live  in  closer 
relationship  to  man,  and  the  opportunities  for  the  spread  of 
the  infection  are  greater. 

Recently  Tileston  has  reported  2  cases  from  New  Haven, 
Connecticut.^®  Previously  Blake  had  reported  the  presence  of 
the  disease  in  Boston,  Massachusetts.®'*'  There  is  much  rea- 
son to  believe  that  rat-bite  fever  is  much  more  common  in 
the  United  States  than  has  heretofore  been  thought  probable. 

In  1914  Schottmiiller  described  a  streptothrix,  which  he 
named  the  Muris  ratti.^^-  He  found  the  micro-organism  in  eight 
successive  blood  cultures  in  a  case  clinically  diagnosed  as  rat- 
bite  fever.  More  recently  Blake  has  isolated  in  a  fatal  case 
of  a  rat-bite  fever  a  micro-organism  practically  identical  with  that 
of  Schottmiiller.-®  He  obtained  the  germ  in  pure  culture 
from  blood  during  life,  and  from  the  heart's  blood  post-mor- 
tem, and  also  from  a  diseased  mitral  valve.  Futakiioo  and 
others  have  reported  the  finding  of  spirochetes  in  the  skin 
and  lymph-nodes,  with  successful  inoculations  into  animals. 
There  is,  therefore,  no  agreement  as  to  the  true  causative 
agent. 

The  chief  characteristics  of  the  micro-organism  found  by 
Schottmiiller,  Blake  and  Tileston  are  the  following :  It  is  a  branch- 
ing, filamentous  germ  varying  greatly  in  length,  and 
showing  a  tendency  to  fragment  into  smaller  forms  resem- 
bling both  bacilli  and  cocci.  They  stain  with  the  usual  stains, 
and  are  negative  or  faintly  positive  to  Gram's  stain.  They 
are  only  found  in  fresh  blood-smears  taken  during  the  febrile 
periods. 

The  incubation  period  of  rat-bite  fever  varies  from  one  to 
sixty  days,  with  an  average  "of  two  weeks.  The  onset  of  the 
disease  is  characterized  by  a  febrile  attack  with   a  step-like 


RAT- BITE   FEVER.  327 

rise  which,  by  the  end  of  the  third  day,  frequently  reaches 
from  104°  to  105°  F.  (40°  to  40.5°  C).  There  is  then  a  fall  by 
crisis,  after  which  the  temperature  remains  normal  for  a  few 
days,  and  there  is  then  a  repetition  o^  the  attack  described 
above.  The  febrile  attacks  may  continue  over  a  period  of 
many  weeks.  Cases  have  been  reported  in  which  attacks  are 
repeated  at  intervals  of  months,  or  even  years.  Hora  reports 
a  case  in  which  there  were  ten  relapses. 

There  is  also  another  type  of  the  disease  known  as  the 
Abortive  Type.  The  fever  is  not  high,  and  local  symptoms 
are  prominent.  Sometimes  there  is  a  continued  fever,  in 
which  there  are  marked  symptoms  of  the  nervous  system. 

There  is  nearly  always  a  localized  bluish-red  erythema 
with  sharply  marked  outlines  covering-  an  area  of  a  few  inches 
around  the  wound  produced  by  the  bite.  There  may  be  a 
generalized  eruption  consisting  of  bluish-red  spots,  circular 
in  form,  0.5  to  3  cm.  in  size.  They  are  usually  first  noted 
over  the  lymph-nodes  draining  the  region  of  the  bite.  Later 
it  may  spread  over  the  body,  showing  no  special  predilection 
for  any  particular  surfaces.  In  the  course  of  a  few  days 
these  spots  usually  become  ring-shaped,  due  to  fading  of  the 
centers. 

Soon  after  the  bite  of  the  rat  the  site  of  the  wound  be- 
comeS'  red  and  swollen.  An  ulcer  frequently  forms,  and  the 
regional  lymph-glands  become  enlarged.  The  enlargement  of 
the  glands  is  usually  coincident  with  the  onset  of  the  fever, 
which  may  be  accompanied  by  a  sensation  of  chilliness. 

The  characteristic  temperature  curve  following  the  bite  of 
a  rat,  or  that  of  a  ferret,  weasel,  or  cat  which  has  come  closelv 
in  contact  with  rats,  is  an  important  diagnostic  feature.  The 
fever  is  distinguished  from  ordinary  wound  infection  bA'  the 
length  of  the  incubation  period.  In  rat-bite  fever  it  is  usuallv 
several  weeks,  whereas  in  an  ordinar}^  wound  infection  it  is 
only  a  few  hours.  The  local  appearance  of  the  two  types  of 
wounds  may  be  similar.  Abscess  formation  is  rare,  although 
occasionally  there  may  be  necrosis  and  grangrene  at  tlie  seat 
of  the  bite.  An  important  distinguishing  feature  is  a  local- 
ized redness  above  the  joint  nearest  the  site  of  the  wound. 
The  generalized  form  of  the  eruption,  when  typical,  may  be 
regarded  as  pathognomonic.     It  consists  of  fairly  numerous, 


328.  TROPICAL    DISEASES. 

large,  bluish  spots,  which  are  nearly  circular  in  shape  and 
slightly  raised,  with  sharply  defined  margins.  The  spots  vary 
in  size  from  a  few  millimeters  to  4  centimeters  (1.3  in.).  A 
few  days  after  thei^  appearance  they  frequently  become 
ring-shaped,  and  resemble  the  lesions  of  erythema  multi- 
forme. The  spots  disappear  on  pressure ;  do  not  itch  or 
scale.  The  finding  of  the  organism  in  fresh  blood-smears 
may  be  regarded  as  fairly  conclusive. 

The  mortality  in  the  past  has  been  only  about  10  per  cent. 
Death  is  most  usually  due  to  blood-poisoning  during  the  first 
attack. 

TREATMENT. 

The  rat-bite  should  be  immediately  cauterized,  either  with 
pure  carbolic  acid  or  with  the  actual  cautery.  When  done 
within  an  hour  it  is  said  to  be  an  effective  preventive. 

Public-health  measures  should  consist  of  destruction  of 
house-rats  and  the  enforcement  of  regulations  to  bring  about 
rat-proof  construction  in  new  houses,  and,  at  least,  palliative 
structural  changes  in  human  habitations  already  built. 

In  1912  Hata^oi  reported  8  cases  treated  with  salvarsan,  of 
which  5  were  cured  by  the  first  injection.  Of  the  remaining 
3,  1  had  a  single  relapse,  which  subsided  without  further 
treatment.  The  second  was  not  followed  further,  and  the 
third,  a  2j^-year-old  child,  was  not  cured  after  the  third 
injection.  Similar  good  results  with  salvarsan  have  been 
reported  in  India  and  America.  Probably  the  best  results  are 
obtained  by  the  administration  of  0.3  gram  (4.6  grs.)  of 
salvarsan  intravenously. 

RELAPSING   FEVER. 

Relapsing  fever  is  one  of  a  group  of  dangerous  com- 
municable diseases,  characterized  by  fever  of  sudden  onset, 
with  rapid  lysis  after  the  seventh  day,  with  relapses  varying 
from  one  to  seven  days  in  their  frequency.  The  disease  is 
caused  by  a  spirillum  which  is  constantly  present  in  the  blood 
during  the  febrile  periods. 

It  is  a  disease  that  is  extensively  distributed  throughout 
the  tropical  and  temperate  zones.  Unlike  most  other  diseases, 
the  type  of  organism  frequently  varies  in  the  different  coun- 


RELAPSING    FEVER.  329 

tries.  For  instance,  in  Europe  the  spirillum  is  of  the  type 
described  by  Schaudin ;  in  the  United  States,  that  of  Novy ; 
in  West  Africa,  that  of  Button ;  in  India,  that  of  Carter.  The 
micro-organisms  in  the  different  countries  vary  somewhat  in  their 
morphology  and  cultural  characteristics.  Relapsing  fever  also 
differs  from  other  diseases,  in  that  it  seems  to  be  transmitted 
by  different  insects.  For  instance,  it  seems  possible  that  it 
may  be  transmitted  by  ordinary  ticks,  bedbugs,  fleas,  biting 
flies  and  "lice.  It  is  also  shown  by  Leishman^''^  t\^2it  the 
Spirocheta  duttoni  may  be  transmitted  hereditarily  in  the  tick. 
Positive  results  have  been  obtained  in  the  second  generation, 
the  bites  of  which  were  infective  for  mice  and  monkeys. 
Third  generation  infections  among'  ticks,  so  far,  have  failed. 

Febris  recurrens,  spirillum  fever,  five-day  fever,  typhus 
recurrens,  icteric  typhus,  remittent  fever,  bilious  typhoid, 
and  epidemic  remittent  fever  are  synonymous  names  for  this 
infection. 

Relapsing  fever  has  figured  in  medical  literature  since 
the  very  earliest  times.  It  was  known  to  Hippocrates,  who 
described  an  epidemic  in  Thasos.  However,  there  are  no 
further  references  contained  in  medical  literature  until  1770, 
when  it  was  described  by  Rutty  as  a  disease  common  in  Ire- 
land. Obermeyer  observed  a  spirochete  in  the  blood  in  1868, 
but  did  not  publish  the  result  of  his  observations  until  1873 
after  having  had  an  opportunity  to  witness  a  subsequent  out- 
break and  verify  his  observation.  The  micro-organism  was 
named  S.  obermeieri  by  Cohn  in  1875.  In  1874  it  was  named 
6".  recurrcntis  by  Lebert.  Obermeyer's  observations  were  con- 
firmed by  Miinch,  of  Moscow,  when  he  inoculated  blood  from 
a  person  sick  with  the  disease  into  a  healthy  human  being, 
with  positive  results.  Metchnikoft'  later  made  successful 
inoculations  into  mice  and  monkeys.  In  1904,  Philip.  Ross 
and  Milne,  and  still  later,  Dutton  and  Todd,  discovered  in 
Africa  that  the  spirochete  was  communicated  by  tlie  bite  of 
the  tick  OrnitJiodonis  mouhata. 

The  disease  occurs  in  Great  Britain,  especially  in  Ireland, 
Norway,  Denmark,  Germany,  Russia  and  Turkey.  Severe 
outbreaks  and  many  epidemics  of  the  disease  have  taken  place 
in  Russia.  It  also  occurs  in  Egypt,  the  Sudan,  Algeria,  Congo 
Free  State,  Angola  and  German  East  Africa.     It  is  very  com- 


330  TROPICAL   DISEASES. 

mon  in  China,  and  cases  have  been  reported  from  Hong  Kong. 
It  is  also  common  in  Sumatra  and  India.  Its  last  known 
appearance  in  the  United  States  was  in  New  York  and  Phila- 
delphia, in  1869.  Some  textbooks  state  that  the  disease  occurs 
in  the  Philippine  Islands,  but  it  has  not  been  reliably  reported 
from  that  country.  It  is  also  suspected  to  exist  extensively 
in  Central  and  South  America,  but  reliable  data  are  lacking. 

Animal  experiments  have  shown  that  at  least  one  form  of 
relapsing  fever  is  caused  by  the  6^.  recurrcntis,  which  is  a  deli- 
cate, spiral  filament,  from  7  to  9  microns  in  length  and  25 
microns  in  breadth,  with  a  long  flagellum,  which  adds  an 
additional  5  to  7  microns  to  its  length.  The  parasite  usually 
has  from  3  to  6  spirals.  In  fresh  blood  preparations  the 
micro-organism  is  propelled  by  the  flagellum,  and  shows 
active  screw-like  movements.  Occasionally  very  long  flagella 
are  seen,  and  lengths  up  to  100  microns  have  been  reported. 
The  disease  is  probably  transmitted  by  some  blood-sucking 
insect.  The  bedbug  has  been  frequently  implicated.  Ticks 
are  also,  in  all  probability,  responsible  for  its  transmission,  as 
well  as  a  number  of  other  insects.  It  may  also  be  transmitted 
by  direct  inoculations.  Accidental  infections  in  laboratories 
have  been  frequent. 

The  life  cycle  of  the  5".  recurrcntis  is  not  definitely  known. 
Fever  occurs  during  the  time  the  spirochetes  are  in  the  blood, 
and  when  they  disappear  from  the  blood  the  temperature  falls 
to  normal.  It  is  not  known  definitely  whether  the  fever  is 
due  to  a  toxin.  Immune  bodies  are  supposed  to  kill  most  of 
the  spirochetes,  but  a  certain  number  remain  resistant,  and 
recurring  attacks  of  fever  take  place,  A  temporary  immun- 
ity, which  may  last  for  several  months,  is  usually  acquired. 
Serum  from  immunized  animals  shows  definite  protective  and 
curative  properties. 

Necropsy  reveals  an  enlargement  of  the  liver  and  spleen. 
The  latter  organ  sometimes  attains  huge  size,  and  extends  well 
down  to  the  pubes.  On  section  the  spleen  is  dark-colored, 
soft,  with  enlarged  follicles  with  congestion  and  cellular  in- 
crease. The  liver  is  enlarged,  the  lobules  poorly  defined,  and 
cloudy  swelling  occurs.  The  kidneys  are  enlarged  and  con- 
gested, with  cloudy  swelling  and  fatty  degeneration.  The 
lungs  often  are  hypostatic.     The  bronchi  are  generally  con- 


RELAPSING    FEVER.  331 

gested.  There  is  usually  a  marked  polymorphonuclear  leuco- 
cytosis. 

The  incubation  period  is  said  to  vary  between  two  and 
twelve  days,  and  is  believed  never  to  be  longer  than  fourteen 
days.  The  onset  is  usually  sudden,  although  in  a  small  per- 
centage of  cases  it  is  gradual,  with  rheumatic-like  pains,  head- 
ache and  constipation.  When  the  disease  has  a  sudden  onset 
there  is  usually  a  severe  chill,  pains  in  the  back  and  limbs, 
with  epigastric  pain  and  tenderness  associated  with  consider- 
able debility.  The  face  becomes  flushed,  the  conjunctiva 
injected,  and  the  temperature  may  rise  to  104°  F.  (40°  C.) 
with  a  proportionate  pulse  rate  up  to  112.  The  fever  remains 
nearly  stationary  until  the  sixth  or  seventh  day,  when  it  falls 
by  rapid  lysis.  The  skin  is  yellowish  in  color,  hot,  and  usu- 
ally damp  from  perspiration.  Frequently  there  is  a  rose- 
colored  macular  eruption,  which  disappears  on  pressure  upon 
the  thorax,  abdomen  and  legs.  The  tongue  has  good  tone,  is 
pointed,  red  at  the  tip,  and  the  remainder  heavily  covered 
with  white  fur.  There  is  usually  constipation.  The  liver  is 
enlarged  and  tender,  as  well  as  the  spleen.  There  are  no 
changes  in  the  heart.  The  pulse  is  that  of  ordinary  fever. 
There  is  reduction  in  the  number  of  erythrocytes  and  in  the 
percentage  of  hemoglobin,  with  a  polymorphonuclear  leuco- 
cytosis.  Spirochetes  may  be  seen  in  the  blood,  and  occasion- 
ally are  inclosed  in  a  leucocyte.  A  cough  and  other  bronchial 
symptoms  are  common.  The  crisis  is  usually  preceded  bv  a 
severe  chill,  after  which  there  is  violent  perspiration  or  diar- 
rhea, often  with  epistaxis.  The  temperature  falls  rapidly  dur- 
ing the  crisis,  and  the  pulse  and  respirations  assume  normal 
rhythm.  The  patient  usually  falls  into  a  sleep,  and  awakens 
feeling  much  refreshed.  A  remission  then  occurs,  during 
which  the  abdominal  organs  resume  their  natural  size,  and 
the  patient's  strength  gradually  returns.  Usually  about  the 
fourteenth  day  from  the  onset  a  relapse  occurs  with  all  the 
symptoms  of  the  original  attack.     Second  relapses  are  rare. 

The  lungs  and  bronchi  are  frequently  afifected.  Often 
there  is  dysentery,  diarrhea  and  hematemesis.  In  pregnant 
women  abortion  often  takes  place. 

The  mortality  is  usually  below  6  per  cent.,  but  it  may 
vary  considerably  in  different  outbreaks  and  in  different  coun- 


332  TROPICAL    DISEASES. 

tries.  For  instance,  in  Egypt  outbreaks  with  a  mortality  of 
over  14  per  cent,  have  been  reported.  In  the  feeble  and  the 
senile,  death  often  takes  place  at  the  height  of  the  first 
paroxysm.- 

The  temperature  chart  in  relapsing  fever  is  characteristic, 
and  usually  is  of  great  assistance  in  making  a  differential 
diagnosis.  It  may  be  distinguished  from  malaria,  typhus, 
typhoid,  and  yellow  fever,  by  the  presence  of  the  spirochetes 
in  the  blood.     Agglutination  may  also  be  depended  upon. 

TREATMENT. 

Salvarsan  acts  almost  as  a  specific.  Persons  who  have 
been  debilitated  with  long  residence  in  the  tropics  do  not 
seem  to  bear  the  administration  of  salvarsan  well,  and  great 
care  should  be  exercised.  It  is  better  to  begin  with  a  small 
dose,  0.3  or  0.4  gram  (5  or  6  grs.)  of  salvarsan,  and  grad- 
ually increase  the  dose.  Death  has  occurred  even  when  small 
doses  of  salvarsan  have  been  used.  In  view  of  the  specific 
effect  of  salvarsan,  the  use  of  other  drugs  has  been  largely 
discontinued.  Symptomatic  treatment  should  be  carried  out. 
Ice-bags  on  the  head  for  the  headache,  or  the  administration 
of  small  doses  of  caffein  and  acetanilid,  are  indicated.  The 
epigastric  pain  may  be  relieved  by  fomentations  sprinkled 
with  tincture  of  opium.  Vomiting  is  sometimes  treated  with 
considerable  success  with  bismuth  or  iced  champagne.  Effer- 
vescing carbonate  mixtures  are  often  very  useful.  In  brief, 
in  addition  to  the  salvarsan,  the  remaining  treatment  and 
nursing  should  be  the  same  as  in  simple  fever. 

The  prevention  of  the  disease  is  based  upon  personal  and 
domestic  cleanliness,  and  avoidance  of  ticks  and  other  bugs. 
A  mosquito  bed-net,  in  a  thorough  state  of  repair  and  reliably 
tucked  in,  invariably  should  be  used. 

FRAMBESIA. 

Commonly  known  as  yaws,  in  Spanish-speaking  countries, 
for  instance,  in  the  Philippines  and  South  America,  frambesia 
is  frequently  referred  to  as  bubas,  and  in  the  French  colonies 
as  pian.  Continental  authors  generally  use  the  term  fram- 
besia.   The  latter  term  was  first  used  by  Sauvage  in  1750,  on 


FRAMBESIA. 


333 


account  of  the  raspberry-like  appearance  of  the  eruption. 
Tropical  polypapilloma,  Castellani's  spirochetosis,  parangi 
(Ceylon),  buena  (Burma),  puru  (Borneo),  patek  (Nether- 
lands Indies),  coco  (Fiji),  and  tona  (Tonga  Islands)  also  are 
used  synonymously. 

Yaws  is  a  specific  infection  caused  by  a  treponema,  and 
manifests  itself  in  the  early"  stages  by  cauliflower-like  excre- 
scences of  the  skin,  and  later  by  many  manifestations  resem- 
bling syphilis. 


f  yaws,  Polynesian  child. 


The  thirteenth  chapter  of  Leviticus  is  ordinarily  inter- 
preted to  refer  to  leprosy.  It  has  been  suggested  by  Hume, 
Adams,  and  others,  that  the  Israelites  were,  in  reality,  afHicted 
with  yaws.  Apparently  the  first  descriptions  of  the  disease 
made  by  European  physicians  were  based  on  American  experi- 
ences. These  descriptions  refer  generally  to  a  disease  called 
pyans  or  yaya  among  the  natives  of  the  West  Indian  Islands. 
In  1718  Bontius  described  frambesia  as  being  endemic  in  the 
West  Indies,  Java,  Sumatra  and  other  islands  of  the  Eastern 
Hemisphere.  It  is  stated  that  outbreaks  of  frambesia  fre- 
quently occurred  among  African  slaves  en  route  to  America, 
and  that  it  was  customary  to  build  hospitals  for  the  treatment 


334  TROPICAL   DISEASES. 

of  yaws  upon  the  arrival  of  these  slaves  in  the  West  Indies. 
By  some  writers  mal  de  chicot  in  Canada  and  radesyge  in 
Norway  and  Sweden  are  considered  to  have  been  yaws.  In 
the  Philippines,  for  instance,  the  disease  referred  to  nowadays 
as  yaws  very  often  includes  many  skin  affections  which  are 
not  yaws.  It  is  more  than  likely  that  the  descriptions  of 
olden-times  contained  similar  errors.  From  very  early  times 
authors  have  considered  frambesia  to  be  a  form  of  syphilis. 
In  1882  Charlouis  endeavored  to  prove  that  syphilis  and  yaws 
were  two  different  diseases.  Probably  one  of  the  most  classic 
reports  on  the  disease  is  that  by  Numa  Rat,  published  in 
1891.  In  recent  years  the  disease  has  been  very  extensively 
investigated.  Probably  the  most  exhaustive  work  done  is  that 
of  Castellani.  In  some  countries,  in  which  yaws  prevails,  it 
is  customary  for  mothers  directly  to  expose  their  children  to 
those  having-  the  disease.  The  child  that  has  not  had  an 
attack  of  yaws  is  looked  upon  as  being  deficient.  This  prac- 
tice is  especially  common  in  Fiji  and  Samoa. 

Yaws  is  found  in  most  tropical  countries.  It  is  especially 
common  in  the  Philippine  Islands,  Ceylon,  tropical  Africa, 
Fiji,  Samoa,  and  other  islands  of  the  South  Pacific.  It  also 
prevails  very  extensively  throughout  the  West  Indies.  Yaws 
is  seldom  seen  in  China,  and  with  few  exceptions  occurs  only 
in  South  China  through  direct  importation. 

From  time  to  time  many  different  micro-organisms,  especially 
bacteria,  have  been  described  as  the  specific  cause  of  yaws. 
For  instance,  Eijkman  found  peculiar  bacilli.  Pariez  described  a 
micrococcus.  Powell  cultivated  a  yeast  micro-organism.  Nicholls 
and  Watts  isolated  a  coccus,  which,  however,  failed  to  pro- 
duce the  disease  when  inoculated  into  animals.  In  1905 
Castellani  observed  a  treponema,  or  spirillum,  which  he 
named  Treponema  pertenue.  This  organism  is  very  generally 
accepted  as  the  true  causative  agent.  It  is  constantly  present 
in  the  primary  lesion,  and  in  the  unbroken  papules.  It  may 
also  be  found  in  the  spleen,  lymphatic  glands,  bone-marrow, 
and  other  organs.  Up  to  the  present  time  it  has  not  been 
possible  to  demonstrate  the  germ  in  the  blood,  but  blood 
inoculations  result  positively.  In  tertiary  lesions  treponema 
have  not  been  satisfactorily  demonstrated.  Positive  inocula- 
tion experiments  are  recorded  as  early  as  1848.    According  to 


FRAMBESIA.  335 

Charlouis  and  Castellani,  it  is  possible  successfully  to  inocu- 
late syphilitic  patients  with  yaws,  and  yaw  patients  with 
syphilis.  It  would  seem,  however,  that  considerably  more 
work  is  desirable  before  general  acceptance  of  this  statement 
can  be  expected.  In  the  Fiji  Islands,  for  example,  yaws  pre- 
vails very  extensively  among  the  Fijians,  and  no  cases  of 
syphilis  have  been  recorded.  Yet  it  seems  almost  unbeliev- 
able that  the  Fijians,  who  have  been  in  intimate  contact  with 
Europeans  and  Tamils,  among  whom  syphilis  exists,  should 
not  have  been  exposed  to  the  infection  of  syphilis.  Inocula- 
tion experiments  in  the  higher  monkeys  result  positively.  In 
genus  macacus  yaw  lesions  apparently  only  occur  at  the  site 
of  the  inoculation,  whereas  in  the  ourang-outang  lesions 
similar  to  those  in  humans  result  from  experimental  inocula- 
tions. The  disease  is  apparently  neither  hereditary  nor  con- 
genital. The  exact  method  of  its  transmission  is  not  known, 
although  it  is  believed  to  be  by  direct  contact.  Infection, 
however,  is  said  not  to  occur  unless  there  has  been  some  solu- 
tion of  continuity  in  the  skin.  Insect  transmission  has  been 
suspected,  but  not  proved.  No  age  is  exempt,  although  in 
endemic  countries  cases  in  persons  over  12  years  of  age  sel- 
dom occur.  It  is  presumed  that  most  of  them  have  had  the 
disease  in  childhood.  One  attack  apparently  confers  immun- 
ity. The  apparent  freedom  of  the  Fijians  from  syphilis  would 
lead  to  the  inference  that  perhaps  an  attack  of  yaws  confers 
immunity  to  syphilis,  much  in  the  same  way  as  an  attack  of 
cow-pox  protects  against  smallpox. 

The  Treponema  pertenne  is  slender  and  spiral-shaped,  and 
varies  in  length  from  18  to  20  microns.  Some  difference  exists 
in  the  diameter  of  the  spirillum.  It  is  difficult  to  stain,  al- 
though fairly  good  results  may  be  obtained  with  the  Giemsa 
or  the  Leishman  method.  The  ends  of  the  parasite  are  often 
pointed,  although  this  is  not  constant.  At  times  there  is  a 
bulbous  expansion  of  an  end,  which  may,  perhaps,  be  due  to 
folding.  There  are  from  six  to  twenty  coils.  These  may  be 
more  or  less  evenly  distributed,  or  they  may  be  concentrated 
in  one  small  section  of  the  spirillum.  Tlie  treponema  of  A-aws 
resembles  that  of  syphilis  ver}^  closely.  The  distinction  is  at 
present  not  definite,  and  the  differentiation  depends  largely 
on  the  ability  and  experience  of  the  laboratory  worker.    Inoc- 


336  TROPICAL   DISEASES. 

ulation  experiments  indicate  that  the  spirillum  of  yaws  and 
that  of  syphilis  are  two  distinct  entities,  as  they  apparently 
produce  totally  different  lesions.  Castellani,  in  1911,  showed 
me  ah  apparent  case  of  syphilis  in  a  boy  whom  he  had  suc- 
cessfully inoculated  with  yaws,  thus  affording  additional  evi- 
dence that  they  are  distinct.  The  facts  previously  mentioned 
with  regard  to  the  absence  of  syphilis  among  Fijians  are,  how- 
ever, very  difficult  to  reconcile  with  the  Ceylon  experience. 
Various  forms  of  bacteria  may  be  found  in  the  open  lesions 
of  yaws,  but  these  are  not  believed  to  have  any  special  patho- 
genic significance. 

There  are  no  reliable  data  available  to  prove  that  yaws 
primarily  causes  death,  but  the  disease  has  been  observed  in 
persons  dying  of  other  diseases.  In  the  more  advanced  cases 
of  yaws,  ordinarily  described  as  the  tertiary  stage,  lesions 
similar  to  those  of  syphilis  may  be  found.  Gummata,  how- 
ever, have  not  been  reported.  Bone  lesions  are  exceed- 
ingly common,  especially  those  accompanied  by  atrophy  and 
absorption.  Extensive  ulceration  with  sinus  formation,  espe- 
cially of  the  feet,  is  very  common  in  untreated  cases.  The 
foot  may  be  huge  in  size  and  resemble  a  mycetoma.  Ulcera- 
tion and  necrosis  of  the  bones,  particularly  those  of  the  head, 
producing  scars  similar  to  those  seen  in  syphilis,  are  also 
common.  Scars  on  the  frontal  bone  are  frequently  seen.  Peri- 
ostitis, especially  of  the  anterior  tibial  surfaces,  is  common. 

There  is  considerable  difference  of  opinion  as  to  the  true 
primary  lesion  in  yaws.  Many  observers  regard  the  so-called 
"mother  yaw"  as  the  primary  lesion.  Others  regard  yaws  as 
occurring  in  three  stages,  and  believe  that  the  characteristic 
skin  eruption  of  yaws  is  a  secondary  manifestation.  It  may 
be  stated,  however,  that  no  satisfactory  description  has  been 
given  of  an  initial  lesion  other  than  that  of  the  primary  yaw. 
The  exact  mechanism  by  which  infection  is  transmitted  to  the 
human  being  has  not  been  satisfactorily  proved.  It  is  assumed 
to  be  a  contact  infection.  Certain  it  is  that  successful  inocu- 
lation can  be  made  by  rubbing  material  from  a  yaw  lesion  on 
the  skin  of  a  child  who  has  heretofore  not  been  afflicted  with 
the  disease.  Mosquito  and  insect  transmission  have  also  been 
suspected,  but  no  satisfactory  proof  exists.  Perivascular 
mononuclear  infiltration  and  endothelial  proliferation  in  the 


FRAMBESIA.  337 

walls  of  the  blood-vessels,  which  are  so  characteristic  of 
syphilis,  have  not  been  reported  in  frambesia.  The  typical 
skin  lesion  or  yaw  is  a  granuloma.  After  it  has  reached  a 
certain  stage  there  are  evidences  of  hyperkeratosis.  Castellani 
and  Chalmers  state  that  they  have  observed  the  presence  of 
a  large  number  of  polychromatic  cells  of  different  sizes,  larger 
than  normal  erythrocytes,  and  some  distinctly  smaller.  Some 
of  the  bodies  show  peculiar  chromatin  dots,  and  in  micro- 
scopic specimens  in  which  these  peculiar  cells  are  found  tre- 
ponemata  are  always  present. 

Like  syphilis,  yaws  may  be  divided  into  primary,  second- 
ary and  tertiary  stages.  There  is  considerable  dispute  as  to 
the  primary  lesion.  Most  tropical  observers  of  large  experi- 
ence are  of  the  opinion  that  the  first  yaw  is  the  primary  lesion, 
and  that  the  subsequent  eruption  is  a  secondary  manifesta- 
tion. Yaws  is  not  a  disease  which  covers  any  distinct  period 
of  time.  Visible  evidences  of  yaws  may  last  from  a  few  weeks 
to  years,  and  even  throughout  a  lifetime,  if  the  disease  remains 
untreated.  However,  there  may  be  periods  during  which  it 
would  be  difficult  to  demonstrate  the  lesions. 

The  incubation  period  of  yaws  is  from  two  weeks  upward 
although  it  is  rare  for  more  than  five  weeks  to  elapse  after 
exposure  to  the  disease.  The  appearance  of  a  primary  lesion 
is  usually  preceded  by  pains  in  the  muscles  and  joints,  head- 
ache, irregular  temperature,  anorexia,  and  a  feeling  of  ill- 
being.  In  brief,  the  symptoms  are  similar  to  those  in  the 
contraction  of  any  acute  infection.  The  onset  is  followed 
within  a  period  of  a  week  by  a  papule.  This  is  apparently 
pushed  up  from  the  rete  Malpighii  through  the  epidermis, 
which  breaks  over  the  summits  of  the  papule  and  splits  into 
radiating  lines  from  the  center.  When  the  papule  reaches  an 
elevation  of  about  a  millimeter  above  the  surface  a  yellow 
point  may  be  observed  at  the  apex,  which  consists  of  pus  con- 
fined under  the  epidermis.  A  hair  frequently  projects  through 
the  center  of  the  little  pustule.  This  papule  may  result  in  a 
typical  yaw,  or  further  growth  may  be  entirely  arrested.  If 
growth  continues  it  results  in  a  rounded  excrescence,  which 
may  vary  from  a  few  millimeters  to  several  centimeters  in 
diameter.  It  is  reddish  bronze  in  color,  and  formed  somewhat 
like  a  cauliflower.    The  name  cauliflower  excrescences  is  fre- 


338  TROPICAL   DISEASES. 

quently  applied  to  a  yaw.  The  lesion  is  distinctly  crust-like 
in  character.  It  is  usually  irregularly  round  in  outline,  and 
may  rise  a  centimeter  above  the  surface.  The  primary  lesion 
is  not  indurated,  but  frequently  painful;  in  the  later  stages, 
however,  it  is  quite  painless.  The  primary  lesion  may  be 
located  on  any  part  of  the  body,  although  in  males  the  anal 
region,  and  in  females  the  mammary  region  is  most  common. 
In  some  countries,  in  which  it  is  customary  to  carry  children 
on  the  hip,  mothers  receive  the  infection  at  the  point  where 
lesions  on  the  limbs  of  the  child  come  in  contact  with  the 
mother.  The  so-called  primary  lesion  may  heal  before  the 
general  eruption  begins,  but,  as  a  rule,  it  is  present  when  the 
secondary  eruption  occurs.  It  is  often  stated  that  the  primary 
lesion  leaves  a  whitish  scar,  but  this  may  also  occur  from 
other  lesions  which  are  present  during  the  secondary  eruption. 
The  secondary  eruption  usually  begins  within  from  one  to 
three  months  after  the  appearance  of  the  primary  yaw,  and  is 
usually  preceded  by  the  same  constitutional  symptoms  which 
occurred  just  prior  to  the  appearance  of  the  primary  lesion. 
The  secondary  eruption  is  very  similar  to  that  of  the  primary 
lesion.  There  first  appear  minute  roundish  papules  several 
millimeters  in  diameter.  These  occur  on  various  parts  of  the 
body.  There  is  the  same  formation  of  pus.  There  is  con- 
siderable difference  in  the  rate  of  development  of  the  eruption, 
some  remaining  in  the  papular  stage  for  a  considerable  period 
of  time,  and  some  developing  rapidly  into  the  cauliflower-like 
appearance  heretofore  described.  The  papules  gradually  be- 
come absorbed,  and  leave  furfuraceous  patches.  In  the  dark- 
skinned  races  distinct  black  spots  remain.  In  the  white  races 
reddish  spots  remain.  The  eruption  is  not  confined  to  any 
particular  portion  of  the  body,  and  occurs  with  the  same  fre- 
quency upon  extensor  and  flexor  surfaces.  The  back  and  the 
scalp,  however,  is  often  free  of  eruption,  and  most  of  the 
lesions  are  found  on  the  face,  legs  and  arms.  A  decided  con- 
centration in  granuloma  of  larger  size  frequently  occurs  in 
the  anal  region.  The  skin  lesions  usually  disappear  after  a 
period  of  from  three  to  twelve  months,  although  cases  have 
been  observed  in  which  the  eruption  lasted  for  three  years, 
and  there  was  no  evidence  of  its  disappearance.  Successive 
crops  of  lesions  may  appear,  and  thus  the  skin  manifestations 


FRAMBESIA.  339 

may  last  for  a  number  of  years.  The  yaws  are  seldom  painful 
unless  there  is  mechanical  interference  with  motion,  as,  for 
instance,  between  the  toes  and  fingers.  In  addition  to  the 
granuloma  there  may  be  other  eruptions  which  consist  of 
papular,  scaly,  or  occasionally  ulcerative  manifestations.  At 
times  some  of  the  granuloma  break  down  and  ulcers  result. 
Yaws  may  have  a  special  predilection  for  the  palms  of  the 
hands  and  the  soles  of  the  feet.  A  peculiar  papule  has  been 
described  as  occurring  in  the  palms  of  the  hands.  It  consists 
of  a  hard  epidermic  plug,  which  falls  off  spontaneously,  or  is 
easily  pulled  out  and  a  deep  depression  remains. 

There  may  be  inflammation  of  the  periosteum,  but  this  is 
not  so  likely  to  occur  until  after  the  secondary  skin  mani- 
festations have  disappeared.  Neuritis  also  occurs  under  simi- 
lar conditions.  If  the  disease  has  persisted  for  some  time  it 
is  likely  that  there  may  be  some  anemia.  The  total  number 
of  corpuscles  is  sometimes  reduced  to  2,000,000,  and  the  hemo- 
globin to  30  per  cent.  The  leucocytes  usually  vary  from  7000 
to  12,000  per  cubic  millimeter.  There  are  no  characteristic 
changes  in  either  the  red  or  the  white  cells. 

As  in  syphilis,  tertiary  manifestations  may  not  appear  for 
many  years.  Many  observers  deny  the  tertiary  stage  in  yaws, 
attributing  the  symptoms  which  appear  to  syphilis  or  some 
other  affection.  With  the  exception  of  gummata  the  tertiary 
lesions  clinically  may  resemble  those  produced  by  syphilis, 
but  seldom  in  the  severe  form  or  in  manifestations  like  gen- 
eral paralysis  of  the  insane.  Bone  changes  and  sinus  forma- 
tion are  very  common.  In  the  feet  this  condition  sometimes 
resembles  mycetoma,  and  mistakes  in  diagnosis  are  common. 
One  or  both  feet  may  be  enormously  increased  in  size,  due  to 
enlargement  of  the  bones,  as  well  as  an  extensive  infiltration. 
Tortuous  sinuses  run  all  through  the  mass,  and  usually  dis- 
charge foul-smelling  pus.  The  condition  often  begins  with 
dactylitis,  and  gradually  all  the  bones  of  the  feet  may  become 
implicated.  There  is  sloughing,  and  absorption  and  complete 
disappearance  of  the  toes,  or  great  distortion  frequently  takes 
place.  Large  ulcers  over  the  ball  of  the  foot  are  extremely 
common.  The  condition  is  frequently  mistaken  for  leprosy. 
Dactylitis  of  the  hands  is  also  common,  and  extensive  ulcera- 
tions and  great  deformity  occur.     However,  there  is  seldom 


340  TROPICAL   DISEASES. 

so  enormous  an  enlargement  as  in  the  feet.  Ulceration,  espe- 
cially necrosis  of  the  frontal  bone,  are  very  common.  The 
stellate  scars  left  by  syphilis  are  not  seen  in  yaws. 

On  .r-ray  examination  great  rarefaction  is  often  seen  in 
the  bones,  particularly  the  bones  of  the  leg.  Scars  resulting 
from  ulcers  frequently  contract  and  produce  serious  deformi- 
ties of  the  hands  and  feet.  At  times  these  are  associated  with 
bone  lesions,  and  great  distortion  may  take  place.  Bones  are 
sometimes  bent  at  a  right  angle.  The  extensive  ulceration  in 
some  cases  of  yaws  which  have  been  neglected  is  one  of  the 
most  terrible  sights  imaginable,  especially  when  associated 
with  foul-smelling  discharging  ulcers. 

There  has  been  considerable  discussion  as  to  whether 
rhinopharyngitis  mutilans,  or  gangosa,  is  a  distinct  entity  or 
whether  it  is  a  manifestation  of  syphilis  or  yaws.  Ley,  a 
United  States  navy  surgeon  stationed  in  Guam,  described 
rhinopharyngitis  mutilans  as  a  distinct  entity  which  failed  to 
respond  to  treatment.  In  later  years  other  navy  surgeons  at 
Guam  gave  huge  doses  of  potassium  iodid,  and  reported 
cures  in  all  of  the  cases  in  which  it  was  tried.  As  iodid  of 
potassium  is  probably  efficacious  in  yaws  and  in  syphilis,  the 
therapeutic  test,  so  far  as  distinguishing  these  two  diseases, 
is  of  little  value. 

There  are  no  sequelae  of  yaws  which  do  not  properly 
belong  to  the  third  stage  of  the  disease. 

During  the  secondary  stage  the  diagnosis  of  the  disease  is 
comparatively  easy.  The  cauliflower-shaped  excrescences  are 
not  seen  in  any  other  disease.  There  is,  however,  some  likeli- 
hood that  yaws  may  be  confused  with  syphilis.  Verruca 
peruana  is  sometimes  mistaken  for  yaws,  but  it  is  limited 
to  certain  valleys  of  the  Andes,  and  occurs  at  elevations  of 
3000  to  10,000  feet.  The  work  of  Strong  and  his  co-workers, 
in  which  a  definite  organism  for  verruca  was  demonstrated, 
also  eliminates  this  disease. 

Some  authors  have  regarded  frambesia  and  syphilis  as 
different  manifestations  of  the  same  disease.  Others  have 
pointed  out  that  syphilis  occurs  in  all  latitudes  and  climates, 
whereas  yaws  has  been  observed  only  in  tropical  countries. 
Castellani  lias  reported  that  patients  suffering  from  syphilis 
may  contract  yaws,  and  patients  suffering  from  yaws  may 


FRAMBESIA.  341 

contract  syphilis.  He  also  reports  that  monkeys  successfully 
inoculated  with  yaws  do  not  acquire  any  immunity  against 
syphilis.  Adequate  data,  however,  on  these  points  are  not 
available. 

The  primary  lesion  in  yaws  is  practically  always  extra- 
genital. The  secondary  manifestation  of  yaws  is  the  charac- 
teristic yaw,  while  in  syphilis  there  are  mucous  patches,  a 
great  variety  of  skin  lesions,  loss  of  hair,  and  many  other 
symptoms  not  seen  in  yaws.  The  diagnosis  may  be  strength- 
ened by  finding  the  Treponema  pertenue. 

The  prognosis  of  yaws  cannot  be  regarded  as  serious,  and 
it  is  extremely  doubtful  whether  any  deaths  can  be  definitely 
attributed  to  yaws  in  the  secondary  stage.  Hospital  statistics 
have  been  cited  among  which  deaths  are  reported,  but  other 
causes  were  not  satisfactorily  excluded.  The  long  duration 
and  the  possible  tertiary  manifestations  of  yaws  make  it  rank 
as  a  serious  malady. 

TREATMENT. 

Since  the  advent  of  salvarsan  and  the  products  closely 
allied  to  it  the  treatment  of  yaws  has  been  greatly  simplified, 
lodid  of  potassium  or  other  drugs  are  no  longer  needed 
Ehrlich's  compound,  with  its  variations,  is  much  nearer  a  true 
specific  for  yaws  than  it  is  for  syphilis.  Usually  an  intra- 
venous injection  of  0.6  gram  (10  grs.)  of  salvarsan  is  suffi- 
cient to  bring  about  a  rapid  cure.  However,  it  has  been 
deemed  advisable  to  repeat  the  treatment  at  least  once  or 
twice,  in  order  to  guard  against  the  possibility  of  tertiary 
manifestations.  The  rapidity  with  which  salvarsan  causes  the 
skin  eruptions  in  yaws  to  disappear  is  almost  unbelievable. 
Extensive  granulomatous  masses  all  over  the  body  are  fre- 
quently absorbed,  and  the  skin,  in  so  far  as  discolorization  is 
concerned,  may  return  to  normal  within  a  period  of  two 
weeks.  The  technic  for  injection  should  be  the  same  as  for 
syphilis.  As  intravenous  injections  are  the  most  effective, 
other  modes  of  administration  should  be  disregarded.  The 
various  local  antiseptic  washes  which  have  been  recommended 
are  now  seldom  necessary.  In  the  tertiary  stage,  amputation 
of  the  hands  or  feet  is  sometimes  indicated.  An  artificial  limh 
is  often  more  serviceable  than  the  deformed  natural  member. 


342  TROPICAL   DISEASES.  ; 

As  a  prophylactic  measure,  persons  residing  in  areas  in 
which  yaws  occurs  should  be  careful  to  prevent  solution  of 
continuity  in  the  skin,  and  when  abrasions  do  occur  a  protec- 
tive collodium  or  proper  dressing  should  be  immediately 
applied.  Doctors,  nurses,  and  others  coming  in  actual  contact 
with  yaws  cases  should  immediately  disinfect  their  hands 
thoroughly  after  having  been  exposed.  Persons  sufifering 
with  yaws  should  be  isolated  in  separate  rooms,  and  have 
their  own  toilet  articles  and  food  utensils. 

ORIENTAL   SORE. 

Oriental  sore  is  a  specific  ulcerating  granuloma  of  the  skin, 
caused  by  Leishmania  tropica,  and  the  disease  occurs  in  cir- 
cumscribed areas  in  tropical  countries.  This  type  of  tropical 
ulcer  is  also  known  as  Delhi  boil,  Bagdad  boil,  bouton 
d'Orient,  chancre  du  Sahara,  endemische  Beulenkrankheit, 
Aleppo  boil,  Biskra  boil,  yearly  boil,  granuloma  endemicum 
(Brooke),  Sudan  nodules,  Leishmaniasis  (Wright),  and  Leish- 
man  nodules. 

Descriptions  of  the  disease  are  available  as  early  as  the 
eighteenth  century.  With  the  advent  of  bacteriology,  many 
organisms  have  been  described  by  different  authors  as  the 
cause  of  the  disease.  However,  it  was  not  until  1903,  when 
Wright  described  bodies  similar  to  those  found  in  kala-azar, 
that  the  etiology  of  Oriental  sore  was  placed  upon  a  definite 
basis.  Wright's  work  has  been  frequently  confirmed  by 
workers  in  tropical  diseases. 

Oriental  sore  occurs  in  many  tropical  and  subtropical 
countries.  It  is  especially  prevalent,  however,  in  Morocco, 
Tunis,  Tripoli,  Egypt,  Crete,  Congo,  Syria,  Asia  Minor,  Meso- 
potamia, Persia,  and  many  parts  of  India.  Occasionally  cases 
are  reported  from  Brazil,  British  Guiana,  and  in  temperate 
climates.  A  case  was  described  as  having  occurred  in  Boston 
a  few  years  ago, 

The  incubation  period  may  be  days,  weeks,  or  months. 
The  short  incubation  period  is  established  by  the  appearance 
of  the  disease  in  a  few  days  in  new  arrivals  in  endemic  areas. 

Oriental  sore  is  caused  by  the  Leishmania  tropica  (Wright). 
In  1908  Nicoll  first  cultivated  the  parasite  on  blood-agar.     It 


ORIENTAL    SORE.  343 

grew  slowly,  and  produced  flagellate  and  division  forms  on 
the  fourth  day,  and  by  the  tenth  day  rosettes  appeared  which 
were  visible  to  the  naked  eye.  A  typical  flagellate  measures 
from  40  to  45  microns,  with  a  breadth  of  2  to  4  microns.  The 
organism  is  apparently  exactly  the  same  as  that  of  kala-azar, 
although  it  gives  rise  to  no  constitutional  symptoms  which 
resemble  that  disease.  The  Oriental  sore  has  been  success- 
fully inoculated  into  monkeys  from  cultures. 

In  the  common  ulcerative  variety  there  is  usually  atrophy 
and  disappearance  of  the  epithelium,  with  extensive  cellular 
infiltration  of  the  corium  and  papillae.  Many  interpapillary 
down-growths  occur  in  the  rete.  There  are  usually  vertical 
epithelial  columns  extending  deeply  downward,  with  a  few 
cells  and  isolated  masses  of  cell  infiltration.  The  sore  may 
vary  from  5  or  6  to  several  centimeters  in  diameter. 

The  disease  may  be  transmitted  from  person  to  person  by 
absorption  of  the  virus  through  an  abraded  surface,  or  through 
small  wounds  or  ulcers.  Insects,  especially  flies,  have  been 
suspected  of  transmitting  the  disease.  It  is  inoculable  from 
man  to  man.  Whether  there  is  a  definite  life  cycle  of  the 
organism  in  the  fly  or  mosquito  has  not  been  satisfactorily 
demonstrated,  although  it  is  more  than  likely  that  these 
insects  are  at  times  concerned  in  the  transmission  of  the 
disease. 

The  sore  begins  with  a  minute  itching  papule,  which  has 
a  tendency  to  increase  in  size.  In  a  short  time,  which  period 
may  vary  from  a  few  days  to  several  weeks,  the  papule 
becomes  covered  with  fine  paper-like  scales.  A  crust  soon 
results,  and  if  this  is  removed  a  sore  is  found  underneath. 
This  soon  increases  in  size,  and  discharges  a  scanty,  ichorous 
material.  This  discharge  at  times  may  undergo  crust  forma- 
tion, and  the  discharge  temporarily  ceases.  Extension  of  the 
ulcer  takes  place  by  erosion  inward,  and  there  are  sharp-cut 
jagged  edges.  Granulations  speedily  break  down.  Subsidiary 
ulcers  may  occur  around  the  parent  ulcer,  with  which  they  all 
ultimately  merge.  In  untreated  cases  healing  may  begin  in 
a  few  months,  but  it  may  extend  over  a  year.  Ultimately  a 
cicatrix  forms,  which,  upon  contraction,  produces  various  de- 
formities. The  ulcers  of  the  face  are  often  severe,  and  may 
be  single  or  multiple.     No  very  characteristic  blood  changes 


344  TROPICAL   DISEASES. 

have  been  reported.  The  ulcers  usually  occur  upon  the  uncov- 
ered portions  of  the  body,  and  are  very  frequently  upon  the 
hands  and  feet.  They  are  seldom  seen  on  the  palmar  surfaces 
of  the  extremities  or  in  the  scalp.  There  seems  to  be  no 
special  race  immunity,  all  classes  being-  prone  to  be  attacked. 
Various  types  of  the  disease  have  been  described.  The  com- 
mon variety  consists  of  several  nodules  which  ulcerate  slowly, 
and  in  some  cases  there  is  fever  and  enlarg^ement  of  the  spleen. 
There  is  a  verrucose  type,  which  has  been  described  by  Fergu- 
son and  Richards.  There  is  also  a  non-ulcerative  variety, 
characterized  by  the  presence  of  pinkish  nodules  which  never 
seem  to  ulcerate. 

When  the  disease  occurs  in  endemic  form  the  diagnosis  is 
not  very  difficult.  This  may  depend  upon  a  few  eruptive  ele- 
ments, often  only  one  lesion,  situated  on  an  uncovered  part, 
or  in  a  characteristic  papule  which  slowly  enlarges  and  gradually 
undergoes  ulcer  formation.  The  presence  of  the  Leishmania 
tropica  micro-organism  is  characteristic  and  sufficiently  diag- 
nostic in  itself. 

The  prognosis  is  excellent  so  far  as  life  is  concerned.  At 
times  the  sores  may  become  phagedenic. 

TREATMENT. 

Treatment,  on  the  whole,  has  been  rather  unsatisfactory. 
The  destruction  of  the  ulcer  with  a  caustic  has  been  recom- 
mended. It  is  doubtful  whether  these  are  of  any  great  value. 
Antiseptic  applications  and  frequent  cleansings  are  indicated. 
Cases  observed  in  the  Tonga  Islands  healed  quickly  by  thor- 
ough irrigation  with  bichlorid  of  mercury  solutions  and 
dressings  of  wet  bichlorid.  Ulcers  that  have  been  actively 
treated  for  a  few  weeks  should  be  treated  with  a  benign  oint- 
ment like  vaselin  or  lanolin,  to  be  followed  later  with  the 
stronger  antiseptics.  Tonics  for  those  who  are  anemic  or 
otherwise  below  par  are  rational  therapeutic  accessories. 

SPRUE. 

As  synonyms  for  this  infection  the  terms  tropical  diarrhea, 
tropical  aphthae,  Ceylon  sore  mouth,  Cochin  China  diarrhea, 
and  spruw  (Dutch)  are  generally  employed. 


SPRUE.  345 

Sprue  is  a  disease  which  manifests  itself  by  chronic  patchy 
inflammation  of  the  gastrointestinal  tract,  resembling  aphth- 
ous stomatitis.  It  is  characterized  by  the  passage  of  periodic, 
copious,  whitish,  frothy,  fecal  discharges. 

The  disease  was  described  in  1766  by  Hillary,  of  Barbados, 
under  the  name  of  aphthoides  chronica.  Later  descriptions 
were  contributed  by  observers  in  India  and  Java.  More 
recently  the  disease  has  been  described  by  the  French  in 
Cochin  China.  In  1880  Manson  clearly  defined  the  disease, 
and  somewhat  later  an  excellent  description  was  given  by  Van 
der  Burg.  Since  the  descriptions  of  Alanson  and  Van  der 
Burg,  sprue  has  been  recognized  as  a  definite  clinical  entity, 
and  descriptive  articles  have  been  numerous.  More  recently 
Ashford,  of  Porto  Rico,  has  made  extensive  contributions,  and 
several  British  writers  also  have  studied  the  disease  at  length. 

Sprue  is  found  in  tropical  and  semitropical  countries,  but 
no  cases  have  been  found  in  permanent  residents  of  the  tem- 
perate zone.  The  disease  occurs  in  the  West  Indies,  Malaya, 
Sumatra,  Java,  Siam,  Cochin  China,  Ceylon,  India,  the  Fiji 
Islands,  the  Philippines  and  Korea. 

Residence  for  several  years  in  countries  in  which  sprue 
occurs  seems  to  be  one  of  the  essentials  to  contracting  the 
disease.  Exhausting  gastrointestinal  affections — for  instance, 
the  diarrheas  and  the  dysenteries — may  terminate  in  sprue. 
Other  conditions  which  lower  the  vitality  also  are  considered  as 
being  important  predisposing  elements.  Specific  micro-organisms 
have  been  described  from  time  to  time,  but  none  of  them  has 
as  yet  received  universal  acceptance.  One  of  the  latest  of 
these  is  a  monilia  described  by  Ashford, 1^3  of  Porto  Rico. 
He  reports  that  in  pure  culture  5  drops  injected  into  the  mus- 
cles of  a  Belgian  hare  caused  death  in  seventy-five  hours,  with 
enormous  production  of  intestinal  gas  and  diarrhea.  Also  that 
the  germ  was  recovered  from  the  spleen,  liver,  and  other 
organs,  in  pure  culture  a  few  hours  after  death.  He  also 
reports  that  this  monilia  can  be  regularly  found  in  bread. 

Pyorrhea  alveolaris  seems  to  be  associated  with  nearly 
every  case.  This  condition,  however,  is  very  common  in  the 
tropics  among  people  who  do  not  have  sprue. 

The  deficiency  theory  of  the  cause  of  sprue  has  received 
considerable  attention,  and  has  been  ably  presented  by  Cantlie. 


346  TROPICAL   DISEASES. 

The  writer  has  seen  no  cases  of  sprue  in  countries  like  the 
Philippines,  India,  Ceylon,  the  Fiji  Islands,  and  Sumatra, 
among  natives,  although  it  was  quite  common  among  Euro- 
peans. 

With  the  exception  of  the  lesions  found  in  the  intestinal 
tract,  there  are  no  important  changes  in  the  remaining  organs. 
As  a  rule,  the  tissues  are  abnormally  dry.  Fat  is  completely 
absent.  The  muscles  and  viscera  are,  as  a  rule,  anemic  and 
atrophied.  Occasionally  there  is  fatty  or  granular  degenera- 
tion of  the  pancreatic  cells. 

The  intestines  are  extremely  thin  and  almost  translucent. 
The  serous  coat  is  not  much  changed.  The  muscular  coats 
are  atrophied.  In  some  areas  the  mucosa  shows  fibrous 
change.  The  mucous  membrane,  from  the  mouth  to  the  anus, 
usually  in  patchy  form,  is  superficially  eroded  and  intersti- 
tially  atrophied.  The  interior  of  the  intestines  is  coated  with 
a  thick  layer  of  grayish,  sticky  mucus  overlying  patches  of 
congestion,  erosion  or  ulceration.  Frequently  there  are  also 
found  pigmented  areas  and  thin  scars  or  cicatricial  patches. 
Villi  are  often  completely  destroyed.  Small  nodular  indura- 
tions several  millimeters  in  size  are  frequently  seen.  These, 
on  section,  are  found  to  be  minute,  cyst-like  dilatations  of  the 
follicles,  and  contain  a  mucopurulent  material.  As  a  rule,  the 
erosion  is  moSt  marked  in  the  lower  part  of  the  ileum  and  the 
upper  part  of  the  large  bowel.  The  mesenteric  glands  ordi- 
narily are  large  and  pigmented. 

In  the  absence  of  definite  etiology  the  pathology  must  be 
largely  speculative.  Whether  the  first  pathologic  changes  are 
due  to  physical  exhaustion,  whether  the  disease  depends  upon 
a  specific  organism  or  upon  deficiency  causes,  or  whether 
there  is  a  combination  of  these  factors,  is  unknown. 

Hyperactivity  of  the  liver  may  be  regarded  as  one  of  the 
first  steps  in  the  development  of  the  disease,  and  this  soon 
results  in  exhaustion  of  the  hepatic  function.  Similar  hyper- 
activity in  other  digestive  glands  is  also  usually  assumed. 
This  results  from  chemical  changes  in  the  food,  with  the 
resultant  formation  of  chemical  changes  leading  to  the  condi- 
tions which  produce  the  fermentative  diarrheas.  Analysis  of 
stools  indicates  the  presence  of  the  ordinary  elements  of  the 
bile,  notwithstanding  the  fact  that  pale  stools  would  indicate 


SPRUE,  347 

their  absence.  Post-mortem  examinations  show  that  the  feces 
are  usually  normally  bile-stained  in  their  upper  portion,  and 
gradually  become  pale  as  the  rectum  is  reached.  Apparently 
bile  is  formed,  but,,  no  bilirubin.  There  is  excess  fat  in  the 
stools,  the  causation  of  which  is  not  clear.  Halberkaun^O'* 
states  that  instead  of  the  normal  6  to  8  per  cent.,  the  fat  varies 
from  20  to  40  per  cent.,  and  that  this  is  not  due  to  failure  of 
the  fat-splitting  enzymes,  but  to  faulty  absorption  in  the  upper 
intestine. 

Anemia,  especially  in  the  later  stages,  is  one  of  the  char- 
acteristics of  the  disease.  There  is  great  reduction  in  the 
number  of  erythrocytes,  and  the  hemoglobin  index  is  low. 
There  is  no  great  change  in  the  number  of  leucocytes.  There 
may  be  an  increase  in  the  proportion  of  lymphocytes. 

Attacks  of  sprue  vary  greatly  in  intensity.  There  may  be 
only  slight  periodic  digestive  disturbances,  with  small  erosions 
in  the  mouth  or  evidences  of  pyorrhea  alveolaris.  On  the 
other  hand,  there  may  be  extensive  erosion  of  the  mouth  and 
of  the  intestinal  tract,  with  acute  pain  when  food  is  taken. 
The  symptoms  may  vary  between  these  two  extremes,  and 
any  combination  is  possible.  Sprue  may  continue  for  one  or 
two  years,  or  it  may  be  extended  for  ten  years  or  longer. 
Death  finally  comes  from  complete  exhaustion.  The  disease 
is  undoubtedly  greatly  modified  by  treatment  and  climate.  In 
a  typical  case  the  patient,  as  a  rule,  soon  becomes  extremely 
emaciated.  The  complexion  is  dark,  sallow  and  yellowish. 
The  principal  symptoms  complained  of  are  sore  mouth  and 
digestive  disturbances,  with  distention  of  the  abdomen  and 
looseness  of  the  bowels,  especially  soon  after  rising.  Soreness 
extending  from  the  mouth  to  the  anus  is  very  characteristic 
of  the  disease.  The  patient  is  physically  weak,  often  has  loss 
of  memory,  and  is  unable  to  take  physical  exercise,  or  to  be 
capable  of  continuous  application.  Irritability  and  unreason- 
ableness are  common.  On  examination  of  the  mouth  the  sore- 
ness complained  of  will  be  found  to  depend  on  numerous 
lesions  of  the  mucous  membrane.  The  patchy  erosion  appears 
superficial  in  character.  There  is  considerable  difference  in  the 
severity  of  the  mouth  symptoms.  At  times  they  may  com- 
pletely disappear  for  several  weeks,  and  may  be  followed  by 
an  acute  exacerbation.    The  tongue  is  extremely  red  and  raw- 


348  TROPICAL   DISEASES. 

looking.  There  is  extreme  tenderness  of  the  gums.  The  tone 
of  the  tongue  is  excellent,  and  it  is  usually  markedly  pointed 
on  protrusion.  At  times  there  may  be  minute  vesicles  on  its 
surface.  Often  the  erosion  extends  to  the  lips,  and  vesicle  for- 
mation is  common.  The  mucous  surfaces  of  the  cheeks  also 
show  erosion.  Bleeding  does  not  occur  very  often.  An  attack 
of  sprue  usually  begins  with  sore  mouth,  indigestion  and  morn- 
ing diarrhea.  These  frequently  disappear,  and  the  patient  does 
not  recall  having  had  them  until  direct  attention  is  drawn  to 
their  occurrence.  Gradually  the  attacks  increase  in  frequency 
and  in  severity.  If  the  teeth  are  roughened,  especially  the 
molars,  ulcers  may  form  at  the  points  of  friction  with  the 
cheeks.  The  mouth  is  often  very  tender,  and  deglutition  and 
mastication  become  difficult.  Warm  and  spiced  foods  or 
alcohol  may  cause  considerable  pain.  On  swallowing,  a  burn- 
ing pain  is  frequently  felt  along  the  line  of  the  esophagus. 
There  is  usually  a  sensation  of  discomfort  and  distention  after 
meals,  with  eructations.  Vomiting  is  rather  frequent.  After 
the  bowels  have  moved  once  or  twice  the  patient  usually  feels 
considerably  relieved  during  the  remainder  of  the  day.  Bor- 
borygmus  is  very  common.  The  symptoms  usually  become 
very  much  more  pronounced  after  ingestion  of  a  full  mixed 
diet.  As  a  rule,  great  relief  is  obtained  by  a  close  adherence 
to  a  milk  regime. 

The  diarrhea  may  vary  considerably  in  type.  There  may 
be  a  regular  morning  diarrhea,  which  persists  for  weeks,  fol- 
lowed by  a  rest  period  of  several  weeks.  The  quantity  of  the 
stool  is  at  times  enormous,  and  this  symptom  is  one  of  the 
most  characteristic  signs  of  the  disease.  The  stool  consists 
of  pale,  grayish,  pasty,  fermenting,  evil-smelling  masses,  ac- 
companied by  copious  amounts  of  frothy  and  watery  material. 
The  excreta  usually  contain  masses  of  undigested  food  and 
large  amounts  of  oil  and  fatty  acids.  On  voiding  the  stool 
there  is  considerable  relief  from  the  distention.  The  stools 
are  usually  most  active  during  periods  in  which  the  erosion 
of  the  mouth  is  the  greatest.  Microscopic  and  chemic  exami- 
nation of  the  stool  shows  mucus,  epithelial  debris,  many  bac- 
teria, frequently  yeast-like  fungi,  and  often  the  eggs  of  intes- 
tinal parasites.  Analyses  carried  on  by  Harley  and  Goodbody 
showed   that  when   12.99  grams   of  nitrogen   were   adminis- 


SPRUE.  349 

tered,  1.47  grams  of  nitrogen  were  recovered  from  the 
stools,  thus  showing  that  88.86  per  cent,  had  ])een  absorbed. 
When  76.44  grams  of  fat  were  administered,  35.92  grams 
were  recovered,  showing  that  53.01  per  cent,  had  been 
absorbed. 

The  blood  shows  a  low  color  index,  with  the  erythrocytes 
varying,  as  a  rule,  from  1,000,000  to  3,000,000  per  cubic  milli- 
meter. There  may  be  a  slight  reduction  in  the  numl)er  of 
leucocytes.  There  are  no  characteristic  changes  in  the  urine. 
As  the  disease  progresses  the  patient  becomes  emaciated, 
weak  physically,  and  depressed  and  irritable  mentally.  The 
skin  shows  lack  of  proper  nutrition,  and  is  dry  and  rough. 
The  patient  continues  to  lose  weight,  and  typical  cases  of 
sprue  are  mere  skeletons.  The  patients  are  seldom  ill  enough, 
however,  to  take  to  their  beds,  and  most  of  them  drag  out  a 
miserable  existence.  It  is  essentially  a  chronic  disease.  Death 
usually  comes  from  exhaustion.  During  an  acute  attack  car- 
diac failure  often  results.  As  a  rule,  there  is  no  elevation  of 
temperature.  The  pulse  is  that  found  in  ordinary  weak- 
ened conditions,  and  is  not  especially  characteristic  of  sprue. 
Attacks  of  dysentery  are  often  followed  by  sprue.  In  this 
condition  the  stool  gradually  changes  from  the  typical  dysen- 
teric stool  to  that  described  for  sprue.  It  has  been  observed 
lately  that  pyorrhea  alveolaris  is  usually  associated  with 
cases  of  sprue,  but  it  is  not  known  whether  it  is  directly 
associated  with  the  disease.  At  times  there  are  cases  of  sprue 
without  diarrhea,  the  diagnosis  being  based  upon  the  sore 
mouth,  the  distention  of  the  abdomen,  the  anemia,  and  the 
copious  stools,  with  their  sprue  characteristics. 

In  some  cases  which  have  recovered,  permanent  digestive 
disturbances  remain  due  to  glandular  lesions  resulting  in 
atrophy.  Patients  of  this  class  may  be  condemned  to  a  life 
of  dietary  restrictions. 

Severe  hemorrhages  sometimes  accompany  the  attacks. 
Insomnia  is  frequent.  Infections  with  intestinal  parasites, 
especially  the  hookworm,  are  also  common.  Chronic  appen- 
dicitis may  also  result.  Jaundice  occurs  in  a  small  percentage 
of  cases. 

In  well-marked  cases  of  sprue  the  diagnosis  presents  no 
great  difficulty.    The  sore  mouth,  the  intestinal  distention,  the 


350  TROPICAL  DISEASES. 

diarrhea,  and  the  characteristic  large,  fermentative  stools  are 
sufficient  data  upon  which  to  base  a  correct  diagnosis.  The 
raw  sore  condition,  which  extends  from  the  mouth  to  the  anus, 
is  very  characteristic,  and  is  seldom  seen  in  any  other  disease. 
There  is  no  other  diarrheal  disease  which  has  stools  resem- 
bling those  found  in  sprue.  The  characteristic  mouth  lesions, 
with  the  periodic  remissions,  are  also  very  distinctive.  The 
large  percentage  of  fat  found  in  the  stools  is  also  of  consider- 
able diagnostic  importance.  Ordinarily  stomatitis  may  be  ex- 
cluded by  the  absence  of  the  characteristic  discharges.  A 
similar  distinction  applies  to  thrush.  Hill  diarrhea  is  some- 
times confused  with  sprue,  but  in  this  disease  there  are  none  of 
the  characteristic  mouth  lesions.  Sprue,  however,  sometimes 
follows  hill  diarrhea.  Dysentery  may  be  readily  distinguished 
from  sprue  by  the  presence  of  the  causative  organisms  of  the 
various  forms  of  dysentery. 

The  prognosis  in  sprue,  with  a  change  of  climate  to  tem- 
perate regions  and  a  strict  adherence  to  diet,  is  reasonably 
fair,  and  fatal  endings  rarely  occur.  In  cases  which  have 
existed  for  six  months  or  more  without  treatment,  or  change 
to  a  favorable  climate,  the  prognosis  is  not  so  good. 

TREATMENT. 

The  many  treatments  which  have  been  advocated  for  sprue 
are  legion,  and  vary  enormously  in  extent.  None  of  them  can 
be  said  to  be  very  satisfactory.  However,  strict  adherence  to 
the  milk  diet  is  one  of  the  treatments  used  in  the  past  which 
has  given  the  most  consistently  favorable  results.  The  thor- 
ough co-operation  of  the  patient  is  essential.  Everything  which 
can  be  done  to  conserve  the  energy  of  the  patient  is  of  direct 
assistance  in  bringing  about  a  recovery.  A  change  to  a  tem- 
perate climate  is  of  great  importance,  although  many  cases 
recover  in  the  same  environment  in  which  they  contracted  the 
disease.  The  various  diets  which  have  been  prescribed  may 
readily  be  divided  into  the  following  classes : 

1.  Milk  diet. 

2.  Milk  and  fruit  diet. 

3.  Fruit  diet. 

4.  Meat  diet. 

5.  Meat  and  milk  diet. 


SPRUE.  351 

A  careful  survey  of  the  cases  and  treatment  of  sprue  dur- 
ing the  past  few  years  in  the  Philippines,  India,  Sumatra,  Fiji 
Islands  and  Ceylon,  and  of  those  being  treated  in  the  United 
States  shows  rather  conclusively  that  the  milk  diet  gives  the 
most  consistent  relief,  and  results  in  the  greatest  percentage 
of  recoveries.  Recently  Lunn,i05  of  Manila,  has  reported 
success  by  the  use  of  emetin,  neosalvarsan  and  sodium 
cacodylate.  Lunn  administers  0.9  grams  (15  grs.)  of  neo- 
salvarsan intravenously.  The  diarrhea,  he  reports,  usually 
ceases  within  two  days.  The  patient  may  remain  apparently 
well  for  about  a  month,  when  the  symptoms  return.  Neosal- 
varsan is  again  injected,  and  recurrences  do  not  take  place. 
He  reports  one  patient  as  having  gained  twenty-five  pounds 
a  few  weeks  after  this  treatment  was  used.  In  cases  in  which 
there  is  considerable  pyorrhea  alveolaris  a  combination  of 
sodium  cacodylate  and  emetin  hydrochlorid  seems  to  produce 
favorable  results.  A  dose  of  0.05  gram  (%  gr.)  of  sodium 
cacodylate  was  administered  in  a  5-mil  (1.35  fo)  solution  into 
the  gluteal  muscle  at  daily  intervals  for  three  days.  The  daily 
dose  was  then  increased  to  0.10  gram  (1.54  gr.)  for  an 
additional  ten  days.  One-grain  (0.06  Gm.)  doses  of  emetin 
hydrochlorid  were  given  daily  until  twenty  doses  had  been 
taken.  In  some  instances  he  has  found  that  alternate  daily 
doses  of  the  sodium  cacodylate  with  the  emetin  hydrochlo- 
rid give  the  best  results.  The  treatment,  however,  should 
not  be  prolonged  beyond  twenty  doses  for  each  drug.  It  may 
be  possible  that  the  emetin  produces  favorable  results  owing 
to  the  accompanying  pyorrhea  alveolaris.  The  teeth  should 
be  put  into  good  condition  b}^  a  competent  dentist.  Wright 
has  recommended  succinimid  of  mercury  in  pyorrhea  alveo- 
laris, and  reports  a  small  number  of  cases  in  which  it  proved 
of  value.  It  may  be  possible  that  this  drug  might  also  prove 
valuable  in  the  treatment  of  sprue,  and  a  thorough  trial  seems 
to  be  indicated. 

Silver  nitrate  may  be  used  in  treating  the  ulcers  in  the 
mouth,  and  this  often  seems  to  have  a  beneficial  eft'ect  on  the 
disease. 

Wherever  possible,  rest  in  bed  with  special  attention  to 
building  up  the  physical  condition  should  be  insisted  upon. 
In  adopting  the  milk  diet,  modifications  to  suit  the   patient 


352  TROPICAL   DISEASES. 

must  be  worked  out  for  each  individual  case.  Safe  fresh 
cows'  milk  is  desirable,  but  boiling  or  pasteurizing  does  not 
seem  to  be  any  detriment,  and  if  there  is  any  suspicion  as  to 
the  wholesomeness  of  the  milk  this  precaution  should  always 
be  carried  out.  The  milk  should  be  administered,  preferably, 
warm,  and  in  small  quantities.  More  or  less  continuous  sip- 
ping is  the  most  effective  mode  of  administration,  and  the 
patient  should  be  encouraged  to  take  daily  amounts  up  to 
seven  or  eight  pints.  Other  modifications  may  be  necessary, 
as,  for  instance,  additions  of  Vichy  water  or  small  quantities 
of  salt,  or  other  formula  may  have  to  be  adopted  to  suit  the 
individual  needs  of  the  patient.  If  all  forms  of  alimentation 
except  milk  can  be  eliminated  it  will,  in  all  probability,  result 
in  the  earlier  cure  of  the  case.  Brown^os  reports  that  he  con- 
trolled the  diarrhea  with  30-grain  (2  Gms.)  daily  doses  of 
pancreatin,  combined  with  calcium  carbonate  and  tannic  acid. 
With  regard  to  prophylaxis  nothing  definite  can  be  said 
under  this  head.  It  would  seem  desirable,  however,  to  pro- 
vide the  patient  with  separate  table  utensils,  which  are  thor- 
oughly disinfected  after  every  meal.  The  stools,  as  soon  as 
voided,  should  be  incinerated.  If  that  is  not  possible,  they 
should  be  disinfected  with  a  5  per  cent,  solution  of  carbolic 
acid,  or  1 :  500  bichlorid  of  mercury,  or  1 :  500  solution  of 
phenoco.  After  touching  the  patient  or  his  discharges  the 
hands  should  be  disinfected. 

LEISHMANIASIS. 

Kala-azar  is  a  communicable  disease,  chronic  in  type,  with 
irregular  fever  and  enlargement  of  the  spleen,  in  which  there 
is  found  the  Leishman-Donovan  body.  It  is  also  known  as 
kala-azar,  dumdum  fever,  cachectic  fever  and  kala  dukh. 

One  of  the  first  records  of  the  disease  appears  in  the 
Assam  Sanitary  Report  of  1882,  in  which  attention  is  drawn 
to  the  fact  that  the  administration  officers  in  Assam  as  early 
as  1869  reported  a  peculiar  disease  referred  to  by  the  natives 
as  kala-azar.  In  some  sections  of  Assam  entire  districts  were 
depopulated  by  its  ravages.  It  was  soon  observed  that  the 
disease  spread  along  the  lines  of  human  travel.  For  many 
years  it  was  regarded  as  one  of  the  severe  forms  of  malaria, 


LEISHMANIASIS.  353 

but  the  malarial  parasite  could  not  be  demonstrated.  Giles, 
in  1889,  after  an  extended  study  of  the  disease,  concluded  that 
it  was  due  to  the  ancylostome,  because  he  found  the  ova  of 
the  hookworm  in  the  feces  in  practically  all  cases  which  he 
investigated.  The  theory,  however,  did  not  receive  universal 
acceptance.  Dobson  created  considerable  doubt  as  to  the  cor- 
rectness of  the  theory  when  he  showed  that  he  had  found  75 
per  cent,  ancylostome  infection  in  212  cases  of  other  illnesses, 
and  that  in  146  apparently  healthy  men  he  had  found  an 
ancylostome  infection  of  67.12  per  cent.  Rogers  and  Ross 
reinvestigated  the  disease  between  1896  and  1898,  and  came 
to  the  conclusion  that  it  was  malarial  in  nature.  Rogers 
regarded  it  as  the  malignant  type  of  malaria,  and  Ross  as  an 


Fig.  14. — Leishman-Donovan  bodies.     {Da  Costa.) 

infection  secondary  to  malaria.  Bentley,  in  1903,  reported 
it  as  a  malignant  form  of  Malta  fever.  In  1903  Manson 
suggested  that  the  disease  was  probably  due  to  trypanosome 
infection.  Shortly  afterward,  in  the  same  year,  Leishman 
published  a  report  in  which  he  stated  that  at  a  post-mortcui 
of  a  soldier  who  died  in  1900  of  dumdum  fever  he  had  dis- 
covered in  smear  preparations  from  the  spleen  a  number  of 
small  round  or  oval  bodies,  which,  upon  being  stained,  showed 
a  nucleus  and  a  small,  rod-like,  chromatin  mass  set  perpen- 
dicularly to  the  circumference  of  the  larger  nuclear  mass.  In 
the  same  year  he  found  similar  bodies  in  a  rat  which  had  died 
of  nagana,  the  blood  of  which,  during  life,  had  contained  try- 
panosomes.  He  then  surmised  that  the  bodies  found  in  the 
soldier  probably  represented  the  degeneration  forms  of  tr}^- 
panosomes.  In  the  same  year  Donovan  stated  that,  three 
months  previous  to  the  date   of  publication   of   Leishman's 

23 


354  TROPICAL   DISEASES. 

report,  he  had  found  similar  bodies  in  smears  from  the  spleen 
taken  post-mortem  from  cases  said  to  have  died  from  chronic 
malaria.  Later  he  found  identical  bodies  in  blood  taken  from 
the  spleen  during  life  from  a  patient  suiTering  from  irregular 
fever  and  enlarged  spleen,  in  which  no  malarial  parasites 
could  be  found.  Earlier  in  the  year  Marchand  found  similar 
bodies  in  sections  of  the  spleen,  liver  and  bone-marrow,  in  a 
patient  who  had  been  in  the  Peking  campaign.  He  had  been 
ill  for  a  long  time  with  continued  irregular  fever  accompanied 
with  great  enlargement  of  the  spleen  and  anemia.  After  these 
reports  were  published  many  investigators  in  different  parts 
of  the  world  reported  the  presence  of  these  bodies.  Wright, 
of  Boston,  found  parasites  morphologically  indistinguishable 
from  those  found  in  Leishmaniasis  in  the  granulation  cells 
of  Oriental  sore.  This  latter  observation  has  been  frequently 
confirmed. 

The  disease  has  been  more  frequently  reported  from  India 
than  from  any  other  country,  especially  from  Assam.  The 
Garo  hills  is  the  district  in  which  it  first  attracted  attention. 
It  has  also  been  found  in  at  least  four  of  the  provinces  of 
China,  in  Arabia,  Ceylon,  Indo-China,  the  Sudan,  Algeria, 
Crete,  Sicily  and  South  America. 

The  consensus  of  opinion  is  that  the  disease  is  caused  by 
a  Leishmania  donovani  parasite,  and  that  it  is  transmitted  to 
the  human  body  by  some  insect.  There  is  considerable  differ- 
ence of  opinion  as  to  whether  the  parasite  belongs  to  the 
herpetomonas  group  or  to  the  trypanosoma  group  of  protozoa. 
Many  observers  believe  that  the  parasite  is  transmitted  by  the 
clinocoridae.  Price  and  Rogers^^"  report  that  uniform  success 
in  prophylactic  measures  may  be  had  which  is  based  on  the 
observation  that  the  infection  persists  in  houses  and  their 
sites.  Infection  can  practically  always  be  stopped  by  removal 
to  new  quarters  three  or  four  hundred  yards  from  infected 
houses,  and  they  conclude  that  if  the  disease  were  transmitted 
by  flying  insects,  as  mosquitoes  or  flies,  removal  to  this  short 
distance  would  not  Ije  effective.  In  their  experience  a  change 
of  habitations  had  no  effect  in  controlling  malarial  fever. 
From  the  foregoing  they  conclude  that  the  disease  is  trans- 
mitted by  a  non-flying  insect  carrier,  which  is  probably  the 
bedbug.     Measures  for  the  eradication  of  this  insect  prevent 


LEISHMANIASIS.  35 


DD 


the  appearance  of  new  cases.  In  India  the  disease  spreads 
very  slowly  along  the  lanes  of  human  travel,  and  often 
appears  after  the  introduction  of  a  new  individual  who  has 
lately  lived  in  endemic  areas.  Apparently  the  disease  persists 
in  a  given  community  for  about  six  years,  and  then  disap- 
pears, even  though  no  control  measures  have  been  invoked. 

According  to  Rogers  the  parasite  of  Leishmaniasis  belongs 
to  the  genus  Herpctomonas  Icger.  There  are  two  stages,  the 
intracorporeal  and  extracorporeal.  It  has  been  suggested  that 
one  of  these  represents  the  sexual  and  the  other  the  asexual 
form.  The  latter  is  found  in  man,  and,  possibly,  some  other 
vertebrates,  while  the  former  occurs  in  certain  insects,  as  flies 
and  bugs.  The  parasite  is  distributed  throughout  the  body, 
but  it  may  be  found  most  frequently  in  the  endothelial  cells 
of  blood-vessels  and  lymphatics,  and  can  nearly  always  be 
obtained  by  puncture  of  the  spleen.  It  also  occurs  in  the 
blood,  being  found  in  the  polymorphonuclear  and  the  mono- 
nuclear leucocytes,  and  at  rare  intervals  in  the  erythrocytes. 
It  occurs  most  abundantly  in  the  blood  toward  the  termina- 
tion of  the  case.  The  organism  is  a  small,  ovoid  body,  meas- 
uring from  2  to  4  microns  in  diameter.  When  stained  in 
accordance  with  the  Leishman  method  it  shows  lavender- 
colored  chromatin  masses,  one  larger  than  the  other,  inclosed 
in  the  cytoplasm^  which  stains  a  bluish  tint  about  the  peri- 
phery. The  smaller  chromatin  mass  is  the  micronucleus,  and 
is  usually  the  shape  of  a  short  rod  and  is  placed  perpendic- 
ularly or  at  a  tangent  to  the  nucleus ;  and,  also,  stains  more 
deeply  than  the  nucleus.  Multiplication  in  the  body  takes 
place  by  simple  fission.  The  nucleus  and  centrosomes  divide 
first.  The  parasites  are  intracellular,  and  the  cell  is  gradually 
distended  by  the  multiplication  of  the  bodies  until  it  finally 
bursts,  after  which  the  bodies  attack  other  cells  or  are  en- 
gulfed by  the  white  blood-corpuscles.  In  smear  preparations, 
however,  they  may  be  found  free  or  in  clusters.  Sometimes 
several  hundred  parasites  may  be  found  in  a  single  field.  In 
culture  media  the  parasites  enlarge  rapidly.  The  cytoplasm 
becomes  granular,  opaque  and  vacuolated.  The  parasites  mav 
enlarge  up  to  9  microns,  after  which  they  assume  elongated, 
piriform  shapes,  and  become  flagellated.  The  flagellum  occurs 
at  the  rounded  end  of  the  parasite,  and  projects  from  the  body. 


356  TROPICAL   DISEASES. 

This  flagellum  measures  from  15  to  20  microns  in  length,  and 
multiplies  by  longitudinal  fission.  All  attempts  to  transmit 
the  parasite  to  vertebrates  have  failed. 

Leishmaniasis  attacks  both  sexes  and  all  ages,  but  shows 
a  decided  "predilection  for  those  who  are  acclimatized.  In 
other  words,  it  is  more  severe  among  old  residents  than 
among  new  arrivals. 

After  the  parasite  is  introduced  into  the  body,  multiplica- 
tion takes  place  rapidly  in  the  endothelial  cells  of  the  blood- 
vessels and  lymphatics.  The  organs  most  affected  are  the 
liver,  spleen,  bone-marrow  and  the  lymphatic  glands.  The 
parasites  then  rupture  the  membrane  in  which  they  are 
inclosed,  and  are  engulfed  by  the  leucocytes.  Another  stage 
in  the  development  probably  takes  place  in  an  insect  host. 
There  is  a  marked  change  in  the  leucocytes;  also  a  very 
definite  anemia.  The  erythrocytes  may  be  reduced  to  2,500,- 
000,  with  a  proportionate  reduction  in  the  amount  of  hemo- 
globin. Leucopenia  is  definite,  and  in  some  cases  the  number 
of  leucocytes  may  be  reduced  to  1000.  There  is  great  diminu- 
tion in  the  percentage  of  the  polymorphonuclear  leucocytes. 
This  is  supposed  to  predispose  to  bacterial  infections. 

As  a  rule,  the  body  is  very  much  emaciated,  with  marked 
muscular  atrophy.  There  is  enlargement  of  the  spleen,  and 
often  the  liver  may  be  swollen.  Sometimes  there  is  ulceration 
of  the  skin  and  intestines.  The  spleen  is  firm,  deep  red  in 
color,  and  often  shows  malarial  pigment.  The  capsule  is 
thickened,  and  the  trabeculse  are  increased  in  size.  On  sec- 
tion in  smear  preparations  large  numbers  of  parasites  may  be 
found.  The  intralobular  capillaries  of  the  liver  are  dilated 
and  contain  macrophages.  The  bone-marrow  contains  numer- 
ous parasites,  and  the  yellow  marrow  is  usually  red.  Para- 
sites can  frequently  be  found  in  the  ulcers  and  papules  in  the 
skin. 

The  incubation  period  is  unknown.  Cases  have  apparently 
occurred  within  ten  days  after  exposure.  The  disease  is  usu- 
ally ushered  in  with  a  decided  chill,  which  recurs  at  daily 
intervals.  This  is  accompanied  by  an  irregular,  high,  remit- 
tent fever,  with  two  remissions  during  a  twenty-four-hour 
period.  Rogers  regards  the  double  remission  as  one  of  the 
most  important  diagnostic  signs.    Between  the  third  and  sixth 


LEISHMANIASIS.  357 

week  the  temperature  declines,  gradually  reaches  normal,  and 
the  first  febrile  attack  of  the  disease  terminates.  The  spleen 
and  liver  become  enlarged,  and  are  painful  and  tender.  A 
headache  is  frequently  present,  but  it  is  not  severe.  This 
condition  is  followed  by  a  period  of  complete  apyrexia  and 
general  improvement.  Recurrences  may  take  place  at  inter- 
vals of  a  month  or  more.  No  drugs  appear  to  have  much 
influence  on  the  attacks.  These  recurrences  become  more  and 
more  frequent,  until  fever  is  present  more  or  less  all  the  time. 
During  the  remissions  in  temperature  there  is  profuse  sweat- 
ing. Pains  in  the  limbs  are  referred  to  as  similar  to  those  in 
rheumatism.  The  facies  in  kala-azar  are  very  characteristic. 
There  is  an  anxious,  apprehensive  look.  After  the  disease 
has  persisted  for  some  time  there  may  be  edema  of  the  legs, 
cystitis  or  circumscribed  edema.  The  skin  in  white  persons 
often  acquires  a  muddy-gray  color.  The  hair  loses  luster  and 
becomes  brittle.  Petechial  spots  are  common,  as  well  as  epis- 
taxis  and  bleeding  from  the  gums.  Fever  and  enlargement  of 
the  spleen  and  liver  may  continue  for  months,  or  even  for 
periods  as  long  as  two  years.  Intercurrent  diseases  are  com- 
mon, and  many  patients  die  of  dysentery,  tuberculosis  or 
pneumonia.  Marked  changes  in  the  blood  may  be  observed. 
There  is  a  decided  decrease  in  the  number  of  both  red  and 
white  cells,  with  a  constant  reduction  in  the  number  of  leuco- 
cytes. The  tongue  is  usually  clean,  and  the  appetite  remains 
good.  The  abdomen  is  swollen  and  barrel-shaped.  Gentle 
palpation  reveals  the  spleen  well  below  the  costal  margin,  and 
often  as  far  down  as  the  pubis.  It  is  usually  possible  to  out- 
line it  by  a  percussion.  The  liver  is  also  frequentlv  enlarged. 
When  the  liver  and  spleen  are  enlarg-ed  there  are  often  intes- 
tinal disturbances  which  manifest  themselves  as  diarrhea  or 
dyspepsia.  Papular  eruptions  are  frequent  on  the  thighs. 
There  is  often  edema  of  the  lower  extremities,  especially  the 
ankles. 

As  complications,  intercurrent  infections  are  common,  and 
pneumonia,  tuberculosis,  diarrhea,  septicemia,  and  other  bac- 
terial invasions  are  frequent. 

A  remittent  fever  of  several  weeks'  duration,  followed  by 
apyretic  periods  and  finally  by  continuous  chronic  tempera- 
ture,  and   enlargement  of  the   spleen   and   the   characteristic 


358  TROPICAL   DISEASES. 

facies  are  sufficient,  in  most  cases,  to  make  a  reasonably 
accurate  diagnosis.  This,  however,  can  be  confirmed  by 
demonstrating-  the  Leishman-Donovan  bodies.  If  the  bodies 
cannot  be  found  in  the  blood,  punctures  from  the  spleen  fre- 
quently reveal  them.  Before  the  puncture  of  the  spleen  is 
undertaken  most  rig"id  aseptic  precautions  should  be  observed. 
Many  unfortunate  accidents  have  occurred  in  attempting  the 
spleen  puncture.  At  times  leukemia  ma}^  be  confused  with 
Leishmaniasis,  but  the  characteristic  blood  changes  in  leuk- 
emia are  sufficient  to  distinguish  between  the  two  diseases. 
Malarial  fever  also  at  times  confuses  the  diagnosis,  but  the 
characteristic  blood-parasites  serve  to  distinguish  the  two. 
Typhoid  fever  may  be  distinguished  by  the  presence  of  Widal 
reaction,  and  the  characteristic  step-like  rise  in  temperature 
without  the  marked  remissions  which  occur  in  Leishmaniasis. 
Advanced  cases  of  ankylostomiasis  may  also  be  confused  with 
Leishmaniasis.  Appropriate  treatment  for  those  who  have 
ankylostomes  in  the  stools  usually  brings  about  prompt  relief, 
and  the  fever  seldom  is  prolonged  as  in  ankylostomiasis. 

Until  recently  the  prognosis  of  kala-azar  has  been  grave. 
From  70  to  95  per  cent,  of  all  cases  died  within  a  period  of 
two  years.  The  treatment  recently  instituted,  however,  bids 
fairs  to  reduce  this  high  mortality. 

TREATMENT. 
•  Rogers^o^  has  recently  reported  considerable  success  with 
intravenous  injections  of  tartar  emetic.  He  recommends  the 
use  of  ^  mil  (8  m.)  doses  of  2  per  cent,  solution  of  tartar 
emetic  every  two  or  three  days  up  to  tolerance,  which  is  from 
3  to  4  mils  (48.6  to  64.8  m.).  If  gastric  disturbances  occur, 
the  dose  is  slightly  reduced.  No  serious  symptoms  occurred 
when  the  larger  dose  was  given.  The  treatment  is  continued 
until  the  temperature  has  remained  normal  for  several  weeks, 
with  continuous  gain  in  weight  and  the  disappearance  of  the 
parasites  from  the  spleen.  It  is  not  necessary  to  continue 
treatment  until  the  spleen  becomes  normal  in  size.  In  suc- 
cessful cases  the  spleen  diminishes  in  size  after  treatment  has 
been  stopped.  Quinin  is  apparently  useless,  unless  there  is 
an  accompanying  malaria.  Rest  in  bed,  liquid  diet,  and  the 
treatment  generally  applied  to  typhoid  are  applicable  during 


TYPHUS   FEVER.  359 

the  fever  periods.  Manson  has  reported  2  cases  out  of  4  as 
being  benefited  by  intramuscular  injections  of  atoxyl.  He 
administered  it  in  3-grain  (0.19  Gm.)  doses  for  three  days 
for  a  period  of  a  year  or  longer.  Attention  should  also  be 
directed  toward  relieving  the  patient  of  intestinal  parasites 
and  building  up  the  general  health  by  change  in  climate,  good 
food,  and  rest  in  bed. 

Rogers  has  made  extensive  investigations  into  the  pre- 
vention and  control  of  Leishmaniasis,  and  reports  satisfac- 
tory results  by  vacating  buildings  in  which  the  disease  has 
occurred.  The  disease  disappeared  repeatedly  among  laborers 
who  were  transferred  from  infected  buildings  to  uninfected 
quarters.  He  attributes  the  success  of  the  measures  to  the 
elimination  of  bedbugs  and  similar  insects. 

TYPHUS    FEVER. 

Typhus  fever  is  an  acute  infectious  disease  of  doubtful 
origin,  transmitted  by  pediculi,  characterized  by  sudden  onset, 
discrete  maculated  rash,  and  fever  terminating  by  crisis 
usually  at  the  end  of  the  second  week.  Spotted  fever,  ship 
fever,  jail  fever,  exanthematic  typhus,  tabardillo  (^Mexico), 
and  camp  fever  are  the  ordinary  synonyms  for  this  disease. 

It  is  probably  one  of  those  diseases  that  has  been  fre- 
quently confused  with  plague  during  early  historic  times. 
During  the  nineteenth  century  it  was  constantly  confused 
with  typhoid  fever.  The  word  signifies  smoke  or  mist  in 
Greek,  and  was  used  by  Hippocrates  to  describe  any  febrile 
condition  in  which  stupor  was  a  prominent  symptom.  The 
term  typhus  was  first  applied  to  the  disease  by  Boissier  de 
Sauvages  in  the  eigiiteenth  century.  It  came  into  general  use 
through  its  adoption  by  Cullen.  Typhus  has  also  frequently 
been  mistaken  for  relapsing  fever.  The  disease  is  now  known 
to  be  endemic  in  Northwest  India,  Mexico,  Russia,  the  Bal- 
kans, Japan,  China,  and,  no  doubt,  in  many  other  places  where 
poor  sanitation  prevails,  and  where  body  lice  are  common. 
Epidemics  occurred  in  New  York  in  1881  and  1882,  again  in 
1892  and  1893,  and  in  Philadelphia  in  1883.  Briin^o  first 
described  a  disease  resembling  typhus  as  occurring  in  New 
York  in  1896,  and  since  then  he  has  made  frequent  contribu- 


360  TROPICAL   DISEASES. 

tions  on  its  presence.  It  has  since  been  shown  by  Anderson 
and  Goldberger  that  Brill's  disease  and  typhus  have  the  same 
etiology;  the  former,  however,  is  much  milder  in  character. 
The  disease  has  caused  terrible  havoc  on  immigrant  ships,  in 
jails,  or  other  places  where  human  beings  are  compelled  to 
share  quarters  under  crowded  conditions. 

Typhus  fever  is  primarily  a  disease  of  temperate  and  cold 
climates,  but  there  have  been  frequent  outbreaks  in  high  alti- 
tudes in  the  tropics.  It  is  a  disease  of  winter,  and  disap- 
pears with  remarkable  regularity  upon  the  approach  of  warm 
weather.  For  instance,  in  Mexico  during  the  past  few  years, 
probably  epidemics  of  100,000  cases  or  more  have  occurred; 
but  these  promptly  subside  on  the  approach  of  warm  spring 
days.  In  Mexico  the  disease  prevails  almost  entirely  in  the 
high  plateau,  most  of  which  is  from  4000  to  7000  feet  above 
sea  level.  An  outbreak  occurred  in  the  Philippines  in  1913 
in  the  highlands  of  the  Island  of  Mindanao  (altitude,  about 
3000  feet).  It  was  probably  conveyed  there  by  Japanese 
laborers  recently  arrived  from  Japan.  Typhus  had  been  pre- 
vailing in  epidemic  form  in  Japan  just  previous  to  its  appear- 
ance in  the  Philippines.  Severe  epidemics  have  occurred  since 
the  outbreak  of  the  European  war  of  1914.  Serbia  is  probably 
the  country  which  has  suffered  most.  The  outbreak  in  Serbia 
was  so  severe  that  physicians  from  most  of  the  civilized  coun- 
tries of  the  world  answered  the  call  to  go  to  Serbia  to  assist 
in  bringing  the  disease  under  control;  many  physicians  and 
nurses  succumbed  to  the  disease.  The  relief  measures  were 
probably  not  well  started  until  the  approach  of  spring, 
which  makes  it  likely  that  the  disappearance  of  the  disease 
was  due  more  to  warmer  weather  than  to  sanitary  measures. 
It  is,  nevertheless,  true  that  the  measures  which  were  applied 
to  destroy  vermin  in  hospitals  and  other  infested  human 
habitations  must  have  had  considerable  influence  in  reducing 
its  ravages.  The  disease  has  also  prevailed  extensively  among 
the  Austrian  and  Russian  troops.  Typhus  has  been  repeatedly 
carried  into  Germany,  and  as  a  defense  measure  stations  with 
steam  chambers  have  been  established  between  Russia  and 
Germany,  and  all  persons  desiring  to  enter  Germany  must 
pass  through  one  of  these  entlausung  stations,  and  a  certificate 
obtained  to  show  that  they  are  free  from  vermin. 


TYPHUS    FEVER.  361 

At  the  present  time  there  is  much  dispute  with  regard  to 
the  etiology  of  typhus  fever.  Plotz,ii'J  of  Mt.  Sinai  Hos- 
pital, in  New  York,  has  isolated  an  anaerobic  organism  which 
he  claims  is  the  true  etiologic  factor.  He  has  made  serums 
for  the  cure  of  the  disease,  but  the  reports  so  far  published 
are  not  especially  encouraging  as  to  their  value.  Other 
observers  state  that  organisms  similar  to  those  found  by  Plotz 
can  be  recovered  with  the  same  technic  in  other  febrile  condi- 
tions. 

The  discovery  of  the  typhus  organism  has  heretofore  been 
frequently  announced.  Klebsm  found  bacilli  in  1881.  In  the 
same  year  Mott  and  Blore^i^  described  a  minute,  screw-like, 
motile  organism,  as  being  present  in  the  blood  during  life,  and 
certain  micrococcus  bodies  in  the  muscular  fillers  of  the  heart 
after  death.  In  1891  Hlava^^^  described  ovoid  bodies.  In 
1892  Thiomot  and  Calmette^i'*  saw  flagellated  bodies.  In 
brief,  some  research  worker  has  announced  a  typhus  organism 
almost  every  few  years. 

Nicolle,  Anderson  and  Goldbergerii^  have  experimentally 
inoculated  the  disease  into  monkeys.  In  1909  Nicolle^^''  re- 
ported the  transmission  of  typhus  fever  by  the  bite  of  the 
body  louse  (Pcdiculus  vcstimenti).  This  work  has  been  con- 
firmed by  Ricketts  and  Wilder,ii"  and  by  Anderson  and 
Goldberger.118  Anderson,  Goldberger  and  Foster  have  also 
shown  that  the  head  louse  {Pedicnlus  capitis)  also  may  be 
concerned  in  transmitting  the  infection.  The  very  extensive 
experience  in  the  great  war  warrants  the  deduction  that  the 
disease  is  conveyed  entirely  by  vermin.  Body  lice  are  prob- 
ably responsible  for  the  great  majority  of  cases,  but  other 
vermin,  especially  the  head  louse,  may  at  times  be  respon- 
sible. The  disease  may  occur  in  sporadic  form,  especially  the 
mild  type  observed  by  Brill  in  New  York.  Under  these  cir- 
cumstances recognition  is  rather  difficult.  A  mild  type  has 
been  reported  in  Manchuria.  These  mild  outbreaks  have  a 
very  low  mortality.  In  Mexico  the  disease  is  usually  virulent, 
and  the  mortality  often  25  per  cent.  Ricketts,  of  the  Univer- 
sity of  Chicago,  fell  a  victim  to  typhus  while  carrying  on 
research  work  in  Mexico  City.  The  disease  is  associated  with 
overcrowding,  and  can  usually  be  traced  to  conditions  in 
which  there  is  opportunity  for  persons  to  exchange  bod^•  lice. 


362  TROPICAL   DISEASES. 

During  epidemics  it  is  a  highly  contagious  disease,  and  non- 
immunes in  attendance  upon  patients  are  usually  attacked. 
Nurses,  doctors,  and  other  attendants  are  frequent  victims.  In 
China,  among  a  very  small  group  of  medical  men,  no  less  than 
five  have  lost  their  lives  during  the  past  two  years.  It  is 
stated  that  in  Ireland,  among  1230  physicians  attached  to 
institutions,  550  died  of  the  disease. ^^^ 

The  infective  agent  may  be  found  in  the  peripheral  blood 
Sfbetween  the  second  and  fifth  days  of  the  fever.  The  disap- 
pearance  of  the  virus  of  the  disease  on  the  fifth  day  corre- 
sponds with  the  appearance  of  the  eruption,  and  it  has  been 
held  by  some  authors  that  the  virus  leaves  the  blood  and 
enters  the  skin.  Plotz,  of  Mount  Sinai  Hospital,  New  York, 
finds  an  anaerobic  Gram-staining  bacillus  in  the  circulating 
blood,  which  he  claims  produces  the  disease  on  being  inocu- 
lated in  pure  culture  into  animals. ^^o 

At  autopsy,  as  a  rule,  no  characteristic  lesions  are  found. 
The  organs  present  the  appearance  of  an  acute  infection. 
There  may  be  some  cloudy  swellings  of  the  liver  and  kidneys, 
and  moderate  enlargement  of  the  spleen.  It  is  said  that  if 
death  does  not  occur  until  after  the  second  week,  there  is  no 
enlargement  of  the  spleen. 

The  incubation  period  of  typhus  fever  is  variously  given 
from  four  to  sixteen  days.  Twelve  days  is  probably  a  fair 
average.  In  a  large  number  of  cases  studied  in  Mexico  last 
year  the  incubation  period  was  apparently  ten  days.  The 
invasion,  as  a  rule,  is  abrupt  and  marked  by  chills,  or  some- 
times by  a  single  rigor  that  is  immediately  followed  by  fever, 
headache,  pain  in  the  back  and  in  the  legs.  There  is  con- 
siderable prostration,  and  the  patient  usually  takes  to  his  bed 
immediately.  There  is  a  step-like  rise  in  the  temperature 
until  the  tenth  to  the  thirteenth  day,  and  then  a  fall  by  crisis. 
The  low  point  is  usually  reached  in  twenty-four  hours.  A 
pseudocrisis  sometimes  occurs  on  the  eighth  or  ninth  day. 
The  average  high  point  in  the  temperature  is  between  104° 
and  105°  F.  (40°  and  40.5°  C.).,  but  it  may  go  as  high  as 
107°  F.  (41.6°  C).  In  the  mild  form  the  temperature  is  much 
lower.  In  fatal  cases  the  temperature  may  reach  108°  or  109° 
F.  (42.2°  or  42.7°  C).  The  tongue  is  dry,  swollen  and  cracked, 
and  crustated  with  a  thick,  brown  deposit.    The  tips  and  sides 


TYJ>HUS    FEVER.  363 

of  the  tongue  are  red.  There  may  be  nausea.  Vomiting  is 
rare.  The  bowels  are  usually  constipated.  The  nervous  sys- 
tem is  affected  early  in  the  disease.  The  patient  is  usually 
apathetic  and  drowsy,  and  has  a  dull  expression.  The  delir- 
ium may  vary  from  the  mild  type  to  that  of  the  most  severe 
maniacal  form.  The  eruption  appears  between  the  third  and 
fifth  days,  first  upon  the  abdomen  and  upper  part  of  the  chest, 
and  then  upon  the  extremities  and  face.  The  eruption  is  most 
difftcult  to  distinguish  in  the  colored  races.  It  usually  occurs 
in  three  stages:  first,  erythema;  second,  a  macular  eruption 
which  at  the  beginning  resembles  the  spots  of  typhoid,  vary- 
ing from  1  to  10  millimeters  (^5  to  %  in.)  in  diameter,  and 
gradually  becoming  more  or  less  hemorrhagic;  and  this  is 
followed  by  a  petechial  eruption.  Sometimes  the  rash  appears 
in  the  form  of  rose  spots,  which  may  disappear  on  pressure. 
In  children  the  rash  may  be  severe,  and  resemble  that  of 
measles.  During  the  second  week  the  general  symptoms  are 
much  aggravated.  The  delirium,  as  a  rule,  becomes  very 
intense  as  the  fever  reaches  the  fastigium.  Retention  of  the 
urine  is  common.  Coma  vigil  is  frequent,  in  which  condition 
the  patient  lies  with  the  eyes  open,  but  unconscious..  Car- 
phologia  is  also  common. 

There  is  usually  an  increase  in  the  number  of  erythrocytes 
and  hemoglobin  percentage.  There  is  always  a  leucocytosis 
varying  from  14,000  to  50,000  per  cubic  millimeter.  In  uncom- 
plicated cases  there  may  be  an  increase  of  8  per  cent,  of  the 
polymorphonuclear  cells,  and  a  decrease  of  the  mononuclears 
and  lymphocytes.  In  severe  cases  there  may  be  hypostatic 
congestion  of  the  lungs.  The  heart  also  frequently  becomes 
feeble,  and  there  are  signs  of  myocarditis.  From  the  forego- 
ing it  will  be  appreciated  that  there  may  be  any  number  of 
varieties  of  the  disease,  varying  from  very  mild  cases  to  those 
of  the  more  virulent  type. 

Bronchial  pneumonia  is  the  most  common  complication, 
and  in  some  epidemics  gangrene  of  the  toes,  hands  or  nose 
may  occur;  and  children  frequently  suffer  with  noma  or 
cancrum  oris.  Paralyses  due  to  postfebrile  neuritis  are  infre- 
quent. 

The  mortality  ranges  in  different  epidemics  from  12  to  20 
per  cent.     It  is  very  much  lower  among  the  young.     After 


354  TROPICAL   DISEASES. 

middle  age  the  mortality  rapidly  rises,  and  in  some  epidemics 
reaches  50  per  cent.  Death  usually  occurs  during  the  second 
week,  and  is  probably  due  to  toxin.  One  attack  of  the  disease 
probably  confers  permanent  immunity. 

During  an  epidemic  the  diagnosis  presents  few  difficulties. 
Isolated  cases,  and  especially  mild  cases,  such  as  described  by 
Brill,  may  be  difficult  to  distinguish  from  typhoid  fever.  The 
positive  Widal  reaction  and  blood-cultures  in  the  latter  dis- 
ease will  leave  no  doubt  after  the  first  week.  The  onset  is 
usually  with  chills,  which  are  rare  in  typhoid.  At  times  it  is 
most  difficult,  if  not  impossible,  for  the  most  expert  clinician 
to  make  a  diagnosis.  Malignant  malaria  may  simulate  typhus. 
At  the  termination  of  the  fever  cycle  the  fall  by  crisis  in 
typhus,  and  by  lysis  in  typhoid,  is  an  important  distinguish- 
ing point.  The  more  positive  signs  are  the  leucocytosis, 
associated  with  the  rash,  and  extreme  nervous  prostration. 
Relapsing  fever  can  be  readily  distinguished  from  typhus  by 
the  spirilla  in  the  blood.  Koplik's  spots  and  the  coryza  will 
readily  exclude  measles. 

TREATMENT. 

In  general,  the  treatment  of  typhus  fever  patients  is  in 
every  respect  similar  to  that  of  typhoid.  Hydrotherapy  to 
keep  down  the  temperature  should  be  regularly  employed. 
This  will  probably  relieve  the  nervous  symptoms  as  effec- 
tively as  it  does  in  typhoid  fever.  It  is  well  to  begin  the 
treatment  with  fractional  doses  of  yi  grain  (0.01  Gm.)  of 
calomel  every  hour  until  bowel  action  has  been  obtained,  and 
this  should  be  followed  by  several  tablespoonfuls  of  mag- 
nesium sulphate.  The  heart  must  be  carefully  watched,  and 
if  it  weakens  heart  stimulants  like  strychnin  or  digitalis 
should  be  administered.  Some  authors  have  used  serum  taken 
from  cases  which  have  recently  had  typhus  fever,  and  in  those 
who  are  very  ill  it  is  believed  that  its  intravenous  use  is  a 
procedure  well  worth  trying.  Water  should  be  given  freely. 
For  those  who  have  been  accustomed  to  alcohol,  small  doses 
seem  to  be  of  considerable  value.  The  diet  should  be  liquid 
until  the  fall  in  temperature.  The  patient  should  be  placed, 
preferably,  in  a  well-lighted,  airy  room,  or  treated  on  a  veranda 
or  in  a  tent,  if  climatic  conditions  permit. 


TYPHUS    FEVER.    "  365 

The  researches  of  Nicolle,  Anderson  and  Goldberger,  in 
which  the  transmission  of  the  disease  by  body  lice  was 
definitely  proved,  have  made  it  possible  to  place  the  prophy- 
lactic measures  upon  a  sound  scientific  basis.  The  Pediculus 
vestimenti  being  so  definitely  concerned  in  the  transmission 
of  the  disease,  it  is  quite  possible  to  understand  why 
overcrowded,  filthy  and  unhygienic  surroundings  are  so  inti- 
mately associated  with  typhus.  The  prevention  of  typhus, 
therefore,  resolves  itself  upon  the  eradication  of  the  body 
louse.  This  insect  does  not  travel  far,  except  as  it  may  be 
carried  on  the  bodies  of  people  or  in  baggage.  In  all  preven- 
tive measures  it  is  important  not  only  to  destroy  the  body 
lice,  but  also  their  eggs.  The  patient's  clothes  should  be 
removed  and  thoroughly  boiled  or  treated  with  steam  under 
pressure.  Strong  chemical  solutions  are  not  to  be  depended 
upon  to  kill  the  lice  and  their  eggs.  The  bodies  of  typhus 
patients  and  others  who  have  become  infested  wath  lice  should 
be  washed  with  gasolene.  This  is  necessary,  owing  to  the 
fact  that  the  body  lice  very  frequently  bury  themselves  in  the 
skin,  and  an  oil-removing  substance  like  gasolene  or  ether  is 
essential  to  their  removal.  This  should  be  followed  imme- 
diately with  a  hot  bath.  It  is  also  advisable  to  use  a  very 
strong  alkaline  soap,  and  for  this  purpose  the  so-called  sea- 
water  soap,  when  used  in  fresh  water,  is  of  considerable 
advantage.  Those  who  come  in  contact  with  typhus  patients, 
especially  doctors  and  nurses,  should  take  all  possible  pre- 
cautions against  being  bitten  by  body  lice.  A  fairly  good 
prophylaxis  can  be  obtained  by  using  special  gowns  and 
boots,  the  openings  of  which  are  tightly  closed,  especially  at 
the  neck,  wrists,  and  tops  of  the  boots.  This  may  be  accom- 
plished with  some  elastic  material.  Insect  powders  or  solu- 
tions are  of  some  value  when  applied  to  the  body  and  cloth- 
ing. Powdered  naphthalene  is  fairly  efficient  in  preventing 
the  lice  from  entering  or  living  in  personal  effects.  Eucal- 
yptus, camphor,  oil  of  citronella,  ordinary  kerosene,  and  pow- 
ders composed  of  starch  and  camphor,  are  all  more  or  less 
used.  The  clothing-  of  all  attendants  should  be  frequentlv 
changed,  and  thoroug-hly  boiled  before  being  used  again. 
Whenever  efifective  measures  for  the  destruction  of  body 
vermin  are  carried  out,  the  disease  rapidly  disappears. 


^^  TROPICAL   DISEASES. 

To  prevent  typhus  being  carried  into  a  country,  all  per- 
sons from  infected  regions  should  be  thoroughly  bathed,  and 
all  their  textile  effects  should  be  disinfected  with  steam  under 
pressure  in  a  modern  steam  chamber.  When  no  steam  cham- 
ber is  available,  effects  may  be  boiled  or  steam  used  in  a  tight 
compartment,  as  a  refrigerator  car,  for  instance. 

BUBONIC    PLAGUE. 

Bubonic  plague  is  an  acute,  specific,  dangerous,  communi- 
cable disease,  caused  by  the  Bacillus  pestis,  and  usually  spreads 
to  man  from  rats  through  fleas ;  to  a  slighter  extent  through 
droplet  infection  from  persons  afflicted  with  pneumonic 
plague,  or  by  inoculation.  The  infection  is  known  also  as 
black  death,  pestis,  mahamari  (India),  yeki  (Japan),  and  kota- 
wen  (China). 

It  is  difficult  to  state,  from  a  review  of  the  literature, 
whether  the  disease  described  by  classic  writers  was  the 
bubonic  plague  of  the  present  day.  Any  disease  occurring  in 
epidemic  form  and  causing  a  large  mortality  is  frequently 
referred  to  as  plague.  The  Bible  contains  references  to  an 
epidemic  disease  among  the  Philistines  which  produced  gland- 
ular swellings  in  human  beings  and  killed  rats.  The  first 
more  or  less  reliable  accounts  of  plague  come  from  the  second 
century.  In  the  fourteenth  century  plague  is  estimated  to 
have  destroyed  one-fourth  of  the  population  of  Europe.  The 
disease  occurred  in  epidemic  form  in  Western  Europe  until 
the  middle  of  the  seventeenth  century.  In  London,  in  1665, 
it  raged  virulently,  and  is  said  to  have  been  responsible  for 
70,000  deaths.  It  disappeared  from  Eastern  Europe  in  1884. 
It  made  its  reappearance  in  Europe  at  Oporto  in  1899.  Since 
that  time  small  outbreaks  have  occurred  in  a  number  of  the 
principal  port  cities  in  Italy,  Scotland  and  England.  These 
outbreaks  were  traced  to  ships  that  had  been  trading  with 
India  and  Egypt,  where  plague  appeared  in  1899.  Until  the 
latter  part  of  the  nineteenth  century  the  disease  had  almost 
disappeared,  but  it  was  presumed  that  it  slumbered  in  certain 
parts  of  China.  In  1894  it  appeared  at  Hong  Kong,  and  from 
there  may  be  said  to  have  spread  by  maritime  routes  all  over 
the  earth.     Hong  Kong  is  one  of  the  great  shipping  ports  of 


BUBONIC    PLAGUE.  367 

the  world,  and  as  there  is  very  little  medical  supervision  over 
incoming  and  outgoing  ships,  the  conditions  were  ideal  for 
promoting  the  spread  of  the  disease  unhindered.  The  ports 
of  India  are  first  supposed  to  have  been  infected  from  Hong 
Kong.  Egypt  probably  Ijecame  infected  in  1898  from  India. 
Japan  has  become  infected  a  number  of  times,  and  the  disease 
still  exists  there.  The  infection  was  probably  derived  from 
Hong  Kong-,  and,  perhaps,  at  other  times  through  rats  in 
cargoes  from  India.  The  disease  was  recognized  in  Manila 
in  1899;  probably  a  direct  importation  from  Hong  Kong. 
Some  places  throughout  the  East,  although  in  active  com- 
munication with  plague-infected  centers,  remained  remark- 
ably free  of  the  disease.  Notable  instances  of  this  kind  are 
Singapore,  Java  and  Colombo.  This  freedom  is  probably  due 
to  the  lack  of  docking  facilities,  which  prevented  plague  rats 
from  having  access  to  the  shore.  Eventually  all  of  these 
places  became  infected,  and  during  the  past  few  years  Java 
has  had  an  outbreak,  which  has  already  cost  more  than  a  hun- 
dred thousand  lives.  In  India  the  plague  mortality  goes  into 
the  millions.  In  1899  the  disease  had  reached  South  America, 
and  particularly  afifected  the  ports  of  Buenos  Ayres  and  Rio 
de  Janeiro.  Madagascar  and  Mauritius  have  likewise  suffered 
very  severely.  By  1900  the  disease  reached  San  Francisco 
from  Hong  Kong. 

Numerous  plague  conferences,  both  international  and 
national,  were  held  from  time  to  time,  but  as  the  eti- 
ology of  the  disease  was  not  clearly  understood,  the  rules 
and  regulations  which  were  formulated  accomplished  little. 
However,  apparently  few  cases  occurred  in  places  like 
San  Francisco  (U.  S.),  Glasgow  (Scotland),  Sydney  (Aus- 
tralia), and  other  countries  in  which  good  health  de- 
partments existed  and  energetic  steps  were  taken  to  bring 
the  disease  under  control.  It  was  not  until  1907,  at  the 
Second  India  Plague  Commission  appointed  by  the  British 
Government,  that  the  mode  of  transmission  was  defi- 
nitely proved,  and  prophylactic  measures  based  thereon  be- 
came available. 

Geographically,  the  disease  is  not  confined  to  anv  special 
latitude  or  climate.  The  fact  that  more  cases  and  greater 
spread  have  taken  place  in  the  tropics  is,  in  all  probability,  due 


368  TROPICAL   DISEASES. 

to  the  poor  facilities  which  exist  in  these  countries  for  com- 
bating the  spread  of  epidemic  disease. 

The  records  show  that  the  disease  spreads  as  rapidly  under 
poor  hygienic  conditions  in  Siberia  and  North  China  as  it  does 
in  India  or  other  tropic  regions. 

Yersin  and  Kitasato,i2i  working  in  Hong  Kong  in  1894, 
discovered  independently  the  specific  organism  of  plague. 
The  Bacillus  pestis  may  be  found  in  the  blood,  the  swollen  glands, 
the  sputum,  the  organs,  especially  the  spleen,  and  elsewhere 
in  the  human  body.  The  micro-organism  usually  may  be 
recovered  in  pure  culture  from  characteristic  buboes.  It  is 
a  short,  thick  coccobacillus,  1^  to  2  microns  in  length,  and 
from  YiQ  to  %o  in  breadth.  It  has  round  ends,  and  resembles 
the  organism  of  chicken  cholera.  It  is  a  bipolar  staining 
bacillus,  and  usually  decolorized  with  the  Gram  method. 

Typical  attacks  of  plague  are  produced  when  the  bacillus 
is  inoculated  in  monkeys,  cats,  rats,  guinea-pigs,  squirrels, 
mongooses,  bats  and  marmots.  In  bovines  and  equines  it  only 
produces  local  reactions.  Canines,  birds  and  reptiles  appar- 
ently are  immune.  Plague  causes  epizootic  among  rats,  either 
in  acute  or  chronic  form.  In  the  latter  condition  it  probably 
maintains  itself  between  epidemics.  The  rat  is  probably  the 
true  reservoir  of  the  disease,  and  man  only  its  accidental  vic- 
tim. The  Indian  Plague  Commissioners  of  1908  came  to  the 
following  conclusions :  "Contagion  occurs  in  less  than  3  per 
cent,  of  the  cases,  playing  a  very  small  part  in  the  general 
spread  of  the  disease.  Bubonic  plague  in  man  is  entirely 
dependent  on  the  disease  in  the  rat.  Infection  is  conve3^ed 
from  rat  to  rat,  and  from  rat  to  man  solely  by  the  means  of 
the  rat  flea.  A  case  in  man  is  not  in  itself  infectious.  A 
large  majority  of  cases  occur  singly  in  houses.  When  more 
than  one  case  occurs  in  a  house  the  attacks  are  generally 
simultaneous.  Plague  is  usually  conveyed  from  place  to  place 
by  imported  rat  fleas,  which  are  carried  by  people  on  their 
persons  or  in  their  baggage.  The  human,  agent  himself  may 
escape  infection.  Insanitary  conditions  have  no  relation  to 
the  occurrence  of  plague,  except  in  so  far  as  they  favor  infes- 
tation by  rats.  A  non-epidemic  season  is  bridged  over  by 
acute  plague  in  the  rat  accompanied  by  a  few  cases  in  human 
beings." 


BUBONIC    PLAGUE.  369 

Plague  does  not  flourish  with  equal  virulence  throughout 
the  different  seasons  of  the  year.  For  instance,  for  more  than 
twenty  years  the  annual  plague  curve  of  Hong  Kong  has 
reached  its  fastigium  during  May,  and  its  low  point  during 
December.  This  seasonal  variation  has  not  been  satisfactorily 
explained.  It  is  usually  ascribed  to  the  variations  in  rat  or 
flea  breeding  at  different  times  of  the  year.  Observations 
made  in  Java  showed  clearly  that  during  the  greatest  inci- 
dence of  plague,  the  average  number  of  fleas  per  rat  was  very 
much  higher  than  during  the  period  of  its  lowest  incidence. 

There  is  considerable  difference  in  the  ability  of  different 
species  of  rats  to  convey  the  disease,  as  well  as  a  considerable 
percentage  of  difference  in  the  rats  of  a  given  community. 
The  Indian  Plague  Commission, i^s  for  instance,  found  that  of 
1776  plague-infected  rats  caught  in  Bombay,  1334  were  Epimys 
norvegiciis,  and  also  that  during  the  non-epizootic  period  the 
E.  norvegiciis  was  the  only  rat  in  which  plague  could  be  found, 
notwithstanding  this  species  is  not  nearly  so  numerous  as  the  E. 
rattus.  It  was  stated  that  the  E.  norvegicus  usually  had  about 
double  the  number  of  fleas  found  on  the  E.  rattus.  The  E.  nor- 
vegiciis, however,  is  more  common  in  compounds,  stables,  ware- 
houses, and  grocery-stores ;  whereas  the  E.  rattus  is  frequent  in 
sewers,  drains  and  stables,  and  isi  seldom  found  in  houses  above 
the  third  floor.  It  is  especially  noted  for  its  burrowing  proclivi- 
ties, Creeli24  showed  that  in  Porto  Rico  the  E.  norvegicus  was 
the  most  common,  as  may  be  seen  from  the  following  tables : 

Classification  of  All  Rodents  Examined  in  Porto  Rico 
FROM  June  23  to  January  11,  1913. 

Norvegicus    23,453      Mongoose    233 

Rattus    4,201       Unclassified*    309 

Alexandrinus     5,962                                                              

Musculus    5,137  Total   number  examined    ...   39,295 

Classification  of  Infected  Rodents. 

Norvegicus    Z7       Unclassified    24 

Rattus   4  — 

Alexandrinus   1  66 


*  The  unclassified  were  those  examined  during  the  first  week  of  labo- 
ratory examination. 

24 


370  TROPICAL   DISEASES. 

In  68,667  rats  caught  in  Manila  during  1912  and  1913  the 
proportion  of  the  different  species  was  about  the  same  as  in 
Porto  Rico.  The  Indian  Plague  Commission  showed  that 
transmission  from  rat  to  rat  is  by  means  of  the  rat  flea. 
Cages  were  prepared  in  which  infected  and  health}-  rats  were 
only  separated  by  a  fme  mesh  gauze,  so  as  to  prevent  the 
transmission  of  fleas,  and  no  infection  took  place.  In  other 
cages,  in  which  no  provision  was  made  for  preventing  the 
fleas  from  transferring  themselves  from  sick  rat  to  healthy  rat, 
infection  invariably  took  place.  Healthy  rats  in  cages,  hung 
4  inches  (10.16  cm.)  above  plague-infected  rats,  did  not  con- 
tract the  disease,  although  no  wire  screen  was  used.  This 
was  due  to  the  fact  that  a  flea  cannot  jump  higher  than  4 
inches  (10.16  cm.).  When  the  cages  were  lowered  to  within 
jumping  distance  of  the  infected  rats,  the  healthy  rats  con- 
tracted plague.  Many  variations  of  this  experiment  have  been 
carried  on  by  the  Indian  Plague  Commission  and  other  obser- 
vers, and  the  work  has  now  been  so  thoroughly  confirmed  that 
practically  no  doubt  exists. 

The  flea  directly  concerned  in  the  transmission  of  plague 
is  the  one  usually  found  on  rats,  namely,  the  Pulex  chcopis, 
although  other  fleas  are  believed  to  be  capable  of  conveying 
the  disease.  The  exact  method  by  which  fleas  transmit  plague 
has  not  yet  been  definitely  established.  It  was  assumed  at 
first  that  in  the  act  of  biting  the  human  host  the  plague  flea 
injected  plague  organisms.  Other  observers  were  of  the  opin- 
ion that  infection  was  conveyed  through  defecation  of  the  flea 
at  the  time  it  bit  its  victim,  and  the  itching  caused  by  the 
flea-bite  afforded  an  opportunity  for  the  organisms  to  be 
rubbed  into  the  skin.  More  recent  work  done  at  the  Lister 
Institute  has  shown  that  fleas  usually  regurgitate  plague 
organisms,  and  in  this  way  the  skin  becomes  infected. 

The  Indian  Plague  Commission  believed  the  spread  of 
plague  was  due  to  fleas  being  conveyed  in  merchandise  or  on 
human  beings,  rather  than  by  the  migration  of  rats.  This 
conclusion  is  open  to  considerable  doubt,  because  plague  fleas 
removed  from  their  host  are  very  short-lived,  probabh-  not 
more  than  a  few  days,  and  even  a  shorter  time  under  un- 
favorable conditions  such  as  sunlight.  Experience  in  Manila 
showed  that  practically  every  case  of  plague  could  be  identi- 


BUBONIC    PLAGUE. 


371 


fied  more  or  less  directly  with  fleas  that  were  not  far  removed 
from  a  plague  rat.  But  this  direct  connection  only  became 
apparent  after  considerable  experience  in  finding  rats.  It  is 
generally  found  that  a  dead  plague  rat  could  be  found  in  a 
ceiling  with  cracks,  or  a  floor  with  openings,  or  in  a  hollow 
wall  close  to  a  bed  in  which  the  human  victim  slept.  It  is 
assumed  that  the  plague  flea,  not  finding  another  rat  for  its 
host,  sought  its  human  victim.  It  was  also  possible  in  Manila 
to  prove  that  fleas  were  responsible  for  the  transmission  of 
the  disease,  by  placing  healthy  guinea-pigs  in  the  bed  or  room 
in  which  the  human  victim  died.  In  the  course  of  four  or 
five  hours,  rat  fleas  would  be  found  on  the  guinea-pigs.  If 
permitted  to  remain,  the  guinea-pigs  often  died  of  plague. 


Fig.  15. — Rat  shown  in  bamboo  joint  of  the  floor. 


There  is  much  reason  to  believe  that  so  long  as  fleas  can 
find  rat  hosts  they  will  not  attack  human  beings. 

In  tropical  countries  bamboo  structures  have  been  found 
to  be  directly  associated  with  the  spread  of  the  disease  (see 
illustration).  This  is  due  to  the  fact  that  the  round  bamboo 
joints  make  admirable  harboring  places  for  rats,  and  when  rats 
die  of  plague  the  fleas  leave  these  hiding  places,  and  frequently 
find  a  human  victim.  In  some  sections  of  Manila,  for  instance, 
and  in  many  parts  of  Java,  plague  was  eradicated  by  cement- 
ing the  ends  of  bamboos  used  in  construction. 

Pneumonic  plague  probably  spreads  directly  from  man  to 
man.  For  instance,  in  the  outbreak  in  Manchuria  many  doc- 
tors and  nurses  were  victims  of  the  disease,  but  as  soon  as 
proper  masks  were  used  by  those  caring  for  the  sick  the  infec- 
tion among  attendants  ceased.  Strong  and  Teague  found 
plague  bacilli  in  droplets  of  mucus  expelled  during  coughing, 


372  TROPICAL   DISEASES. 

or  sometimes  even  during  speaking.  Pneumonic  plague  Is 
more  likely  to  spread  in  cold  countries  than  in  warm  coun- 
tries. .This  is  probably  entirely  due  to  lack  of  air  dilution.  It 
is  obvious  that  a  case  of  pneumonic  plague  in  a  house  with 
closed  windows  and  doors  and  inadequate  ventilation,  such 
as  are  the  rule  in  cold  countries,  would  be  more  liable  to  sur- 
charge the  air  with  plague  bacilli.  Whereas  in  tropical  coun- 
tries, where  doors  and  windows  are  kept  open,  the  dilution  of 
the  air  due  to  better  ventilation  would  greatly  diminish  the 
danger  of  spread. 

There  is  no  particular  difference  with  regard  to  the  sex 
incidence  of  plague,  except  in  so  far  as  persons  are  likely  to 
be  exposed  to  rats  or  humans  who  are  suffering  with  pneu- 
monic plague.  In  all  probability,  pneumonic  plague  has  its 
origin  through  the  secondary  invasion  of  the  lung  which 
occurs  in  bubonic  cases.  When  the  lungs  are  involved,  espe- 
cially in  cases  located  in  poor  hygienic  conditions,  its  trans- 
mission directly  by  droplet  infection  from  human  to  human 
is  quite  conceivable,  and  may  be  the  origin  of  a  pneumonic 
outbreak. 

In  California  a  more  or  less  permanent  reservoir  for  plague 
exists  in  ground-squirrels.  Elaborate  measures  have^  been 
taken  to  free  large  farms  of  squirrels,  and,  on  account  of  the 
extensive  work  done,  transmission  to  human  beings  seldom 
takes  place.  It  is  stated  by  some  authors  that  plague  may 
be  found  in  marmots,  and  by  others  in  the  tarabagan.  The 
great  China  epidemic  of  1911  is  said  to  have  begun  among 
trappers  of  these  animals.  The  intense  cold  caused  much 
overcrowding  in  poorly  ventilated  quarters,  with  the  result 
that  the  pneumonic  type  soon  became  predominant.  Large 
numbers  of  laborers  soon  afterward  proceeded  from  North 
China  to  South  China  by  railway.  As  it  is  not  customary  for 
trains  to  run  at  night  in  China,  the  nights  were  spent  in  badly 
ventilated,  overcrowded  lodging-houses.  The  disease,  once 
introduced  among  these  passengers,  spread  with  alarming 
rapidity.  As  these  laborers  proceeded  to  many  provinces  in 
South  China,  they  became  the  centers  of  infection,  and  a 
widespread  epidemic  occurred. 

Outbreaks  of  human  plague  are  almost  invariably  asso- 
ciated with  consideral)le  mortality  among  rats.     In  communi- 


BUBONIC    PLAGUE.  373 

ties  which  have  a  modern  health  service  it  is  customary  to 
make  periodic  examinations  of  rats,  in  order  to  determine 
whether  plague  exists  among  them.  If  it  is  found,  adequate 
steps  are  at  once  taken  to  exterminate  rats  and  bring  the  dis- 
ease under  control.  In  this  way  human  outbreaks  have  been 
reduced  to  small  proportions,  and  not  infrequently  entirely 
prevented. 

The  great  majority  of  human  plague  cases  originate  from 
the  bites  of  fleas  that  have  been  infected  by  biting  rats  suf- 
fering with  the  septicemic  type  of  the  disease.  At  rare  inter- 
vals it  is  possible  to  find  the  probable  site  of  the  entrance 
infection,  and  plague  bacilli  may  be  recovered  from  the  skin 
and  underlying  tissues  involved  in  the  wound  produced  by 
the  bite.  The  bacilli,  after  being  introduced,  travel  by  way 
of  the  lymphatics  to  the  nearest  lymphatic  glands.  The 
resisting-  power  of  the  glands  is  almost  invariably  overcome, 
and  the  infection  then  spreads  to  the  thoracic  duct,  enters  the 
blood-stream,  and  causes  septicemia.  Another  mode  of  en- 
trance into  the  blood  is  probably  through  the  direct  absorp- 
tion caused  by  the  degeneration  of  the  cells  in  the  lymphatic 
glands.  The  glands  most  usually  affected  are  the  femoral, 
the  inguinal,  the  axillary  and  the  cervical.  It  is  noteworthy, 
however,  that  the  fact  that  most  cases  of  plague  implicate  the 
glands  of  the  groin  does  not  necessarily  mean  that  the  infec- 
tion has  entered  through  the  lower  extremities.  In  cases  of 
experimental  human  plague  in  Manila  the  infection  was  intro- 
duced by  a  hypodermic  needle  in  the  arm  in  the  vicinit}-  of 
the  deltoid,  and  in  the  majority  of  cases  the  first  phA'sical  signs 
of  the  disease  were  the  characteristic  bubonic  swellings  of  the 
inguinal  region.  From  the  primary  bubo  the  infection  mav 
travel  up  the  lymphatics,  and  produce  secondary  buboes  in 
other  chains  of  glands.  In  other  instances  it  is  also  quite  pos- 
sible that  the  bacilli  may  gain  direct  entrance  to  the  blood- 
vessels through  injury  to  the  walls  of  the  veins  in  primary 
buboes. 

In  the  pneumonic  variety  transmission  undoubtedly  takes 
place  by  direct  infection  through  the  respiratory  or  ali- 
mentary tract.  Strongi25  and  his  co-workers,  Teague  and 
Growell,!-*^  show  that  the  primary  infection  in  pneumonic 
cases  was  apparently  in  the  bronchi,  and  by  extension  into  the 


374  TROPICAL  DISEASES. 

lung-tissues.  According  to  Simpson,!-'^  infection  also  prob- 
ably takes  place  through  the  intestinal  tract  by  the  consump- 
tion of  plague-infected  food.  But  at  best  this  must  be  a  very 
rare  way  for  the  disease  to  be  transmitted.  Blood-cultures 
made  during  the  febrile  stage  of  the  disease  are  almost  always 
positive  for  the  plague  bacillus. 

The  most  characteristic  pathologic  feature  in  connection 
with  plague  autopsies  is  the  bubo,  of  which  over  50  per  cent, 
are  found,  primarily  in  the  femoral  region.  There  is  consid- 
erable suggillation  in  the  dependent  portions  of  the  body, 
which  has  the  appearance  of  large  black  spots.  It  is  this  sign 
which  led  to  the  name  "black  death."  It  is  also  quite  com- 
mon to  find  very  small  hemorrhages  into  the  skin  which  are 
frequently  not  found  on  the  autopsy  table,  unless  their  pres- 
ence has  been  noted  in  the  living  case.  At  times  there  are 
very  small  nodules  about  a  millimeter  (^5  in.)  in  size  which, 
upon  incision,  exude  a  turbid  fluid  which  contains  plague 
bacilli.  The  primary  bubo  is  found  in  the  lymph-glands  which 
drain  the  area  of  the  skin  that  forms  the  portal  of  entry  of 
the  plague  bacillus.  The  glandular  mass  feels  boggy  and 
elastic.  The  individual  glands  cannot  be  readily  palpated. 
On  section  these  buboes  are  found  to  be  very  edematous,  and 
exude  a  large  amount  of  yellowish  fluid.  The  appearance  of 
a  plague  bubo  is  very  characteristic,  A  large  amount  of  the 
fluid  exudes  as  soon  as  the  skin  over  it  is  incised.  Its  edema- 
tous character  distinguishes  it  readily  from  buboes  due  to 
other  infections.  Plague  bacilli  disappear  from  the  glands 
usually  about  the  time  pus-formation  starts.  The  lesion  in 
the  gland  is  a  hemorrhagic  inflammation  and  coagulation 
necrosis.  Other  glands  located  along  the  lymph-channels  are 
also  involved.  In  severe  septicemic  cases  all  of  the  glands 
may  be  enlarged  and  swollen,  but  large  buboes  are  uncom- 
mon. Secondary  plague  lesions  occur  in  the  lungs,  but  these 
may  be  distinguished  from  primary  pneumonic  cases.  The 
lesions  in  the  lungs  may  be  bronchopneumonic  in  character. 
There  may  be  peripheral  infarcts,  and  the  metastatic  type  of 
infection.  There,  may  be  punctiform  hemorrhages  of  the 
pleura. 

The  spleen  is  usually  enlarged.  The  capsule  is  tense, 
opaque,  and  varies  in  color  from  a  reddish  to  a  bluish  appear- 


BUBONIC    PLAGUE.  Z7o 

ance.  The  capsule  is  often  studded  with  small,  confluent 
hemorrhages.  On  section  it  does  not  collapse  nor  lose  its 
form.  Its  consistence  is  firm.  The  cut  surface  is  grayish  red 
in  color  and  rather  dull  in  appearance.  There  are  usually 
small  infarcts  and  necrotic  nodules.  Cultures  in  the  spleen 
are  usually  positive.  The  liver  shows  changes  found  in  acute 
parenchymatous  inflammation. 

The  changes  in  the  kidney  can  scarcely  be  said  to  be  char- 
acteristic, and  are  those  usually  found  in  acute  febrile  condi- 
tions. There  is  often  degeneration  of  the  tubular  epithelium. 
The  heart  nearly  always  shows  parenchymatous  or  fatty 
degeneration  in  the  myocardium.  The  endocardium,  as  well 
as  the  m3^ocardium,  at  times  shows  small  hemorrhages.  The 
most  common  lesion  is  a  small  hemorrhage  in  the  epicardium. 

The  incubation  period  of  plague  varies  from  two  to  ten 
days.  In  most  cases  it  occurs  within  a  period  of  three  days. 
For  clinical  purposes  the  disease  may  be  divided  into  four 
types :  pestis  minor,  bubonic,  septicemic  plague  and  pneu- 
monic plague. 

Pestis  Minor.  In  this  type  of  plague  the  patient  has  an 
irregular  fever,  swelling  in  the  glands  of  the  groin,  and  pos- 
sibly suppuration.  Very  often  the  patient  is  not  ill  enough 
to  seek  relief.  These  cases  are  commonest  at  the  beginning 
and  end  of  epidemics.  Plague  bacilli  can  usually  be  found  in 
the  glands,  and  in  the  blood,  if  sufficiently  large  quantities  are 
taken  during  the  height  of  the  fever.  Diagnosis  can  often  be 
arrived  at  much  easier  by  searching  for  the  typical  plague 
vesicle,  which  probably  denotes  the  entrance  of  the  infection, 
and  finding  therein  the  plague  bacilli. 

Bubonic  Plague.  There  may  be  prodromal  symptoms,  con- 
sisting of  general  malaise,  headache,  pain  in  the  back,  un- 
easiness, chills,  and  mental  apathy.  This  variet}^  occurs  in 
probably  three-fourths  of  all  the  cases.  The  onset  is  sudden, 
with  a  rise  in  temperature  to  103°  or  104°  F.  (39.4°  or  40° 
C),  with  a  corresponding  increase  of  the  pulse  and  respira- 
tion rate.  There  is  usually  a  marked  increase  in  the  prodro- 
mal symptoms.  The  mental  dullness  is  very  characteristic, 
and  often  leads  to  suspecting  the  disease.  The  patient's 
expression  is  that  of  fear  and  anxiety.  His  eyes  are  blood- 
shot, bright  and  staring.     The  face  is  drawn,  and  often  the 


Z76  TROPICAL   DISEASES. 

nostrils  are  dilated.  The  temperature  may  remit  somewhat 
on  the  second  day,  but  usually  rises  again  almost  immediately 
afterward.  If  recovery  takes  place,  the  fall  of  temperature  is 
usually  by  lysis.  In  fatal  cases  the  temperature  often  falls 
rapidly  to  normal  or  subnormal,  and  then  rises  quickly  to 
107°  F.  (41.6°  C),  followed  by  death.  Glandular  swellings 
become  prominent  on  the  second  day,  and  very  often  can  be 
felt  by  careful  palpation  on  the  first  day.  If  the  patient  sur- 
vives until  the  fourth  day  the  swellings  are  usually  quite  large 
and  distinct.  Suppuration  may  occur,  or,  in  some  instances, 
gangrene.  Suppuration  is  usually  not  regarded  as  a  favorable 
symptom.  Petechige  usually  appear  about  the  third  day,  and 
are  often  referred  to  as  the  so-called  "black  spots"  or 
"tokens  of  death,"  and  gave  to  the  disease  in  the  Middle 
Ages  the  name  of  "black  death."  Hemoptysis  frequently 
occurs.  Plague  bacilli  can  usually  be  found  during  the  high 
fever  periods  of  the  disease.  There  is  a  leucocytosis  from 
90,000  to  100,000,  and  the  red  cells  and  the  hemoglobin  are 
distinctly  increased.  The  increase  in  the  white  count  is  due 
almost  entirely  to  the  polymorphonuclear  leucocytes.  The 
breathing  is  rapid,  the  breath  sounds  are  harsh,  and  there  are 
generally  moist  rales. 

The  urine  is  usually  diminished  in  amount,  and  contains 
albumin  and  casts.  Pregnant  women  generally  abort.  There 
is  low  muttering  delirium,  which  gradually  passes  into  coma. 
Death  usually  occurs  between  the  third  and  fifth  days.  In 
favorable  cases  the  tongue  becomes  moist,  the  pulse  rate  and 
temperature  fall,  and  delirium  gradually  abates.  Even  in 
favorable  cases  buboes  generally  continue  to  enlarge  and 
soften.  If  not  incised,  they  usually  burst  spontaneously.  As 
a  rule,  they  are  very  ill-smelling.  In  these  cases  convalescence 
usually  begins  between  the  sixth  and  tenth  days. 

Septicemic  Plague.  In  this  form  of  the  disease  the  patient 
usually  succumbs  within  three  or  four  days,  and  before  the 
appearance  of  buboes.  The  symptoms  are  similar  to  those  of 
any  general  septicemic  process.  The  degree  of  virulence  and 
rapid  course  of  the  disease  depend  on  the  entry  of  large  num- 
bers of  bacilli  into  the  blood.  The  patient  is  extremely  pros- 
trated from  the  beginning.  He  is  pale  and  apathetic,  and,  as 
a  rule,  there  is  no  great  febrile  reaction.     The  temperature 


BUBONIC    PLAGUE.  177 

may  not  be  above  100°  F.  {Z7 .7°  C).  Vomiting  is  severe, 
and  diarrhea  with  blood  frequently  occurs.  There  are  often 
petechial  hemorrhages  in  the  skin.  Leucopenia  is  the  rule  in 
these  cases.  Briefly,  there  is  an  overwhelming-  infection  in 
which  the  patient  succumbs  before  the  defensive  forces  of  the 
human  organism  have  had  an  opportunity  to  act. 

Pneumonic  Plague.  This  variety  of  plague  must  be  care- 
fully distinguished  from  the  ordinary  inflammation  of  the 
lungs  found  secondary  to  bubonic  plague.  This  is  a  true 
pneumonic  plague,  and  begins  suddenly  with  fever,  shortness 
of  breath,  coug'hing,  and  frequently  pain  in  the  chest.  There 
is  expectoration  of  bloody  mucus,  which  contains  plague 
bacilli.  Cyanosis  comes  on  early.  The  pulse  is  small  and 
rapid.  There  is  early  enlargement  of  the  spleen,  and  death 
usually  occurs  within  four  days.  Recovery  in  this  type  of 
the  disease  is  very  rare.  The  other  symptoms  correspond 
very  closely  to  those  of  pneumonia  caused  by  the  pneumo- 
coccus  or  other  organisms. 

Diagnostic  errors  in  plague  ma}^  have  grave  consequences, 
and  the  first  cases  in  a  community  in  which  plague  is  rare,  or 
has  not  heretofore  appeared,  are  very  likely  to  be  overlooked. 
But  once  the  presence  of  the  disease  is  suspected,  its  diagnosis 
is  comparatively  simple,  and  can  be  made  practically  certain 
by  resort  to  laboratory  methods.  \'ery  often  the  disease  is 
mistaken  for  typhoid  fever;  but  the  appearance  of  the  buboes, 
and  finally  the  demonstration  of  the  plague  organisms,  make 
the  distinction  certain.  The  pneumonic  type  is  very  likely  to 
be  overlooked,  and  very  often  only  attracts  attention  through 
nurses  and  doctors  becoming  affected  with  the  disease.  In 
the  tropics  plague  is  often  confused  with  ordinary  glandular 
fever,  and,  as  a  rule,  many  cases  are  sent  to  plague  hos- 
pitals by  mistake.  The  clinical  examination  alone  usualh' 
will  suffice  to  distinguish  the  disease  with  reasonable  cer- 
tainty. In  glandular  fever  the  glands  are  exceptionaally  hard 
and  movable,  whereas  the  plague  bubo  is  more  in  the  nature 
of  an  edematous  mass,  in  which  it  is  difficult  to  palpate  the 
individual  glands.  There  is  very  little  prostration  in  glandu- 
lar fever,  whereas  in  plague  prostration,  as  a  rule,  it  is  very 
great.  Bacteriologic  diagnosis  based  upon  material  taken 
from  the  gland,  or  by  direct  examination  of  the  blood  may  t)e 


378  TROPICAL   DISEASES. 

depended  upon  to  show  plague.  Films  can  be  made  of  fluid 
drawn  from  the  suspected  bubo  and  stained  with  methylene 
blue,  which  has  been  diluted  with  carbol-fuchsin.  The  pres- 
ence of  the  typical  bipolar  staining  bacilli  is  almost  sufficient 
evidence  upon  which  to  make  conclusive  diagnosis.  An  abso- 
lute diagnosis  must  be  dependent  upon  blood-cultures  and 
animal  experiments.  In  this  way  diagnoses  can  be  confirmed 
by  inoculating  rats  or  guinea-pigs  with  blood  or  material  taken 
from  a  bubo,  and,  upon  the  test  animal  becoming  sick,  further 
inoculations  from  that  animal  into  a  healthy  animal,  which 
should  cause  the  disease. 

The  mortality  from  plague  is  probably  higher  than  that 
from  any  other  epidemic  disease  which  occurs  in  considerable 
numbers.  As  a  rule,  the  mortality  varies  from  80  to  90  per 
cent.,  and  many  outbreaks  have  had  a  mortality  of  95  to  98 
per  cent.  The  prognosis  depends  very  largely  on  the  charac- 
ter of  the  outbreak, — that  is,  upon  the  virulence  of  the  strain 
of  plague  bacilli.  In  the  pneumonic  form  of  the  disease  the 
recorded  mortality  in  reliably  diagnosed  cases  is  100  per  cent. 
The  septicemic  type  has  a  higher  mortality  than  the  bubonic 
variety. 

TREATMENT. 

There  is  no  specific  for  plague.  Many  serums  have  been 
made  from  time  to  time,  but  none  of  these  can  be  said  to  have 
any  appreciable  influence  on  the  mortality  of  the  disease, 
unless  they  have  been  given  during  the  prodromal  or  incuba- 
tion period.  The  treatment  resolves  itself  largely  into  mak- 
ing the  patient  comfortable  and  following  the  same  general 
principles  which  apply  to  the  care  of  fever  patients.  There 
should  be  purgation  and  stimulation,  with  the  use  of  mor- 
phin  to  control  the  pain.  It  is  customary  to  apply  ice  com- 
presses to  the  buboes.  With  regard  to  the  use  of  serum,  while 
there  is  no  satisfactory  evidence  that  it  is  of  value,  there  is 
considerable  evidence  that  it  never  does  any  harm,  and  it  may 
be  of  some  service.  Fever  may  be  controlled  by  sponging  and 
cold  applications.  If  the  buboes  break  down  they  should  be 
incised  and  have  antiseptic  treatment.  Ichthyol  is  frequently 
recommended  for  this  purpose.  The  heart  should  be  sustained 
by  digitalis  and  strychnin.     There  should  be  administration 


BUBONIC    PLAGUE.  379 

of  sufficient  fluid  to  keep  the  kidneys  active.  The  diet  should 
be  of  the  liquid  variety.    Milk  is  usually  w^ell  borne. 

Prophylactic  measures  for  the  control  of  plague  depend 
upon  preventing  rat  fleas  that  have  bitten  plague-infected  rats 
or  human  beings  from  biting  humans.  To  accomplish  this, 
means  the  killing  of  rats  or  removing  them  to  places  remote 
from  human  contact.  The  spread  of  human  plague  is  prob- 
ably greatly  retarded  by  the  fact  that  rat  fleas  do  not  bite  man 
by  choice,  but  only  after  failure  to  gain  lodgment  on  rats. 
It  thus  happens  that  many  persons  contract  the  disease  vvrho 
sleep  in  the  neighborhood  of  places  infested  with  rats.  In 
countries  in  which  bamboo  enters  into  the  construction  of 
houses,  and  particularly  beds  and  furniture,  plague  is  often 
indirectly  spread  through  this  means.  Rats  are  very  fond  of 
nesting  in  bamboo-joints,  and  when  they  happen  to  die  of 
plague  and  the  fleas  have  no  other  rat  to  which  they  can  go, 
they  seek  other  food  supplies,  and  very  often  find  persons 
who  sleep,  for  instance,  in  beds  made  of  bamboo  or  in  the 
vicinity  of  bamboo  structures.  Hollow  walls  in  which  rats 
die  are  also  frequently  directly  concerned  in  transmitting 
plague  to  persons.  Likewise  persons  who  sleep  on  floors 
below  which  there  are  hollow  ceilings,  which  afl^ord  harbor- 
ages for  rats,  are  very  frequently  infected.  Persons  who  go 
about  barefooted  and  barelimbed,  in  the  vicinity  of  rat  nests 
which  have  been  inhabited  by  plague  rats,  are  very  liable  to 
infection.  It  is  quite  noteworthy  that  for  years  it  was  known 
that  persons  who  worked  in  oil  warehouses  or  soiled  their 
clothing  with  kerosene  very  seldom  contracted  the  disease. 
The  reason  for  this,  of  course,  is  now  quite  obvious.  Fleas 
dislike  the  smell  of  kerosene  very  much,  and  will  give  it  a 
wide  berth. 

From  the  foregoing  it  will  be  apparent  that  the  ^.rophy- 
laxis  readily  divides  itself  into  two  classes :  public  and  per- 
sonal. 

Public  Prophylaxis.  This  consists  in  obliterating  rat- 
breeding  places  in  the  vicinity  of  man's  habitations.  This  is 
usually  brought  about  by  preventing  the  construction  of 
hollow  walls,  hollow  ceilings,  posts,  etc.  Rats  are  naturally 
secretive  animals,  and  if  their  means  of  hiding  are  taken  away 
they  are  inclined  to  leave  human  habitations.     In  most  coun- 


380  TROPICAL   DISEASES. 

tries,  especially  in  port  cities,  in  which  plague  is  liable  to  pre- 
vail, ordinances  are  being  gradually  adopted  which  prevent 
the  construction  of  buildings  which  are  not  reasonably  rat- 
proof.  This  also  applies  to  docks  and  piers,  so  that  rats  com- 
ing from  ships  that  have  touched  at  plague-infected  ports  may 
not  find  harborage  on  the  piers.  During  the  presence  of  an 
outbreak  of  plague,  the  primary  measures  for  combating  the 
disease  consist  in  destroying  the  rats,  and  preventing  their 
harborage  near  man.  For  instance,  if  the  problem  concerns 
rat  control  in  a  city,  the  method  employed  by  the  author  in 
Manila  is  probably  the  most  successful: 

A  list  of  the  places  at  which  plague-infected  rats  were 
found  was  made.  Each  was  regarded  as  a  center  of  infection. 
Radiating  lines,  usually  five  in  number,  were  prolonged  from 
this  center,  evenly  spaced  like  the  spokes  of  a  wheel.  Rats 
were  caught  along  these  lines  and  examined.  Plague  rats 
were  seldom  found  more  than  a  few  blocks  away.  The  fur- 
thermost points  at  which  infected  rats  were  found  were  then 
connected  with  a  line.  The  space  inclosed  was  regarded  as 
the  section  of  infection.  The  entire  rat-catching  force,  which 
had  heretofore  been  employed  throughout  the  city,  was  then 
concentrated  along  the  border  of  the  infected  section.  They 
then  commenced  to  move  toward  the  center,  catching  the  rats 
as  they  closed  in.  Behind  them  thorough  rat-proofing  was 
carried  out.  One  section  after  another  was  treated  in  this 
way  until  they  had  all  been  wiped  out.  Once  weekly  there- 
after rats  were  caught  in  the  previously  infected  sections,  and 
at  other  places  which  were  insanitary,  and  which  had'  been 
infected  in  years  gone  by.     This  continued  for  one  year. 

Methods  of  Destroying  Rats.  Rat  trapping  or  poisoning 
is  usually  employed.  The  relative  effectiveness  of  various  rat- 
traps  shows  that  a  wire  spring  or  snap  trap  has  an  efficiency 
of  7.47  as  against  0.97  for  the  wire-cage  trap,  and  0.12  for 
poisoned  bait.  Many  different  forms  of  rat  poisons  are  advo- 
cated. The  one  found  most  successful  in  Manila  consisted  in 
boiling  1  part  white  arsenic  with  4  parts,  by  weight,  of  rice, 
and  distributing  this  about  in  places  frequented  by  rats.  One 
grain  of  the  rice  is  sufficient  to  kill  a  rat.  Recently  (1917) 
researches  at  the  Kasauli  Institute  indicate  that  barium  car- 
bonate  is   very   efficient.      In   seaports   precautions   must  be 


BUBONIC    PLAGUE.  381 

taken  to  prevent  infected  rats  from  gaining  access  to  ves- 
sels, and  also  to  prevent  rats  from  other  ports  from  gaining 
access  to  the  shore.  This  is  best  accomplished  by  thorough 
fumigation  of  such  ships  at  frequent  intervals.  This  is  best 
done  usually  with  a  2  per  cent,  sulphur-dioxid  gas.  Carbon 
monoxid  and  carbon  dioxid  have  been  recommended  from 
time  to  time,  but  are  not  regarded  as  satisfactory,  because 
they  only  kill  the  rat  and  the  flea  escapes.  An  apparatus 
devised  by  Harker  consists  in  using  flue  gases  from  steamers 
or  launches.  This  has  proved  very  successful  in  killing  rats, 
but  failed  to  kill  fleas.  Probably  the  most  successful  agent 
is  hydrocyanic  gas,  but  it  is  so  extremely  dangerous  that  many 
fatalities  have  already  been  recorded  from  its  use. 

Taking  everything  into  consideration,  the  best  method  for 
killing  rats  on  board  ships  is  probably  by  using  sulphur 
dioxid.  This  can  be  readily  generated  in  iron  pots  that  have 
been  set  into  tubs  of  water.  These  are  lighted,  the  places 
tightly  closed,  and  the  gas  allowed  to  remain  for  a  period  of 
at  least  six  hours.  Two  pounds  of  roll  sulphur  for  each  1000 
cubic  feet  of  space  are  sufficient.  Rat-guards  should  be  used 
on  the  lines  by  which  vessels  are  tied  to  wharves,  in  order  to 
prevent  rats  from  passing  back  and  forth.  At  night  the  gang- 
way should  be  lifted.  Vessels  from  plague-infected  ports 
should  also  be  fended  away  from  the  wharf  for  a  distance  oi 
at  least  three  ffeet. 

The  rat  virus,  which  has  been  recommended  from  time  to 
time  for  the  purpose  of  spreading  fatal  disease  among  rats, 
has  proved  very  disappointing.  It  soon  loses  its  efficiency, 
and  when  it  does  act,  often  obscures  the  diagnosis  of  plague 
among  rats. 

In  connection  with  the  foregoing  measures,  provision  must  be 
made  for  isolating  human  cases,  and  adequate  precautions  taken 
to  prevent  fleas  with  which  they  may  have  been  infested  from 
gaining  access  to  healthy  individuals.  It  is  also  deemed  advisable 
to  disinfect  the  sputa  or  excreta  which  come  from  the  plague 
sick.  A  bacteriologic  laboratory  is  an  absolute  essential  in  dealing 
intelligently  with  plague  outbreaks,  where  diagnosis  may  be 
reliably  and  satisfactorily  made. 

Personal  Prophylaxis.  This  consists  of  avoiding  infected 
regions   and    guarding   against    flea-bites.      For    those    who    are 


382  TROPICAL   DISEASES. 

compelled  to  enter  plague-infected  areas  some  measures  of  pre- 
caution may  be  obtained  by  sprinkling  kerosene  or  some  other 
insecticide  about  the  tops  of  the  shoes,  armlets,  and  neck-bands. 
A  much  more  reliable  prophylaxis,  however,  is  found  in  plague 
vaccine.  Hafkine's  and  other  vaccines  give  protection  for  a 
period  of  at  least  six  months  and  perhaps  longer,  and  those  who 
are  constantly  exposed  to  plague  fleas  should  protect  themselves 
in  this  way.  So-called  true  vaccines — that  is,  those  made  with 
attenuated  living  plague  bacilli — are  generally  held  to  be  more 
effective  than  those  made  with  the  dead  bacilli,  as  is  done  with 
the  Hafkine  method.  Those  who  come  in  contact  with  pneu- 
monic plague  should  wear  head-masks  which  may  be  made  of 
Canton  flannel,  with  suitable  eyes  of  celluloid. 

After  plague  has  disappeared  from  a  city  it  is  well  that 
examinations  should  be  made  at  weekly  intervals  of  a  limited 
number  of  rats,  particularly  those  in  areas  in  which  plague  infec- 
tion has  prevailed.  Effective  work  done  in  this  direction  and 
adequate  measures  taken  when  plague-infected  rats  are  found 
will  probably  prevent  outbreaks  among  human  beings. 

FILARIASIS. 

Filariasis,  also  known  as  filarial  disease,  is  an  infection  of 
man  by  any  species  of  filaria,  and  is  transmitted  through  the  bite 
of  a  mosquito  that  contains  microfilaria  obtained  from  an  infected 
man  or  animal.  The  disease  is  characterized  by  various  manifes- 
tations, elephantiasis,  or  swelling  of  the  lower  limbs,  being  the 
most  prominent. 

Reliable  knowledge  with  regard  to  this  disease  begins  in  1863, 
when  Demarquayi28  discovered  in  the  tunica  vaginalis  a  larval 
nematode  in  a  case  of  chylous  dropsy,  which  has  since  been  named 
the  Microfilaria  bancrofti.  The  huge  legs  in  some  cases  of 
filariasis  are  so  striking  that  they  were  noticed  by  ancient  writers, 
who  gave  descriptions  which  clearly  refer  to  elephantiasis.  Chy- 
luria  was  described  in  very  early  times.  In  1812,  for  instance, 
Chapotini29  described  this  condition  among  the  natives  of 
Mauritius.  Wuchereri-^'^  found  filaria  in  1866  in  the  urine  of 
persons  afflicted  with  chyluria.  Lewisi-*^!  made  a  similar  ob- 
servation in  1870,  and  in  1872  discovered  that  the  blood  of  man 
was  the  normal  habitat  of  this  larvail  parasite,  and  named  it 


FILARIASIS.  383 

Filafia  sanguinis  hominis.  In  1876  Bancroft, 1^2  in  Brisbane, 
Australia,  discovered  the  adult  worm.  Cobbold^^^  named  it 
Filaria  bancrofti.  In  later  years  the  subject  has  aroused  in- 
creasing interest,  and  the  disease  is  now  known  to  be  an 
enemy  of  man  throughout  the  tropical  world.  According  to 
Manson,^^*  the  human  circulation  is  the  habitat  of  the  larvae 
of  at  least  five  distinct  species  of  filaria.  Only  one  parasite, 
namely,  the  Filaria  bancrofti,  appears  to  have  any  important 
pathogenic  significance.  The  Filaria  loa  may  also  be  con- 
cerned. 

Filariasis  has  been  foimd  throughout  the  tropical  and  sub- 
tropical world ;  in  Europe,  as  far  north  as  Spain ;  in  America,  at 
Charleston,  S.  C. ;  on  the  other  side  of  the  Equator,  as  far  south 
as  Australia.  In  certain,  parts  of  China  10  per  cent,  of  the  pop- 
ulation are  said  to  harbor  it.  In  some  countries  over  50  per  cent, 
of  the  natives  have  microfilaria  in  their  blood.  According  to 
Bahr,i3^  27.1  per  cent,  of  the  Fijians  harbor  the  microfilaria  in 
their  blood.  Bahr  also  states  that  at  one  time  or  another  nearly 
every  Fijian  is  subject  to  filariasis,  and  concludes  that  with  27.1 
per  cent,  in  whom  it  is  possible  to  demonstrate  microfilaria,  added 
to  25.4  per  cent,  having  symptoms  of  filariasis  without  its  being 
possible  to  demonstrate  the  microfilaria,  there  is  an  infection  rate 
of  52.5  per  cent,  of  the  entire  population.  Heavy  infections  have 
also  been  found  in  the  Friendly  Islands,  Samoa,  Madras,  Deme- 
rara,  the  West  Indies,  the  Philippines,  and  West  Africa.  It  is 
more  than  likely  that  a  careful  research  would  show  the  pres- 
ence of  the  disease  in  practically  all  tropical  countries. 

In  1877  Cobbold^^^  showed  that  the  microfilaria  was  intro- 
duced into  the  body  by  the  bite  of  the  mosquito.  Soon  afterward 
Manson,!-^'''  working  in  Amoy,  proved  the  transmission  of  the 
disease  by  the  mosquito.  According  to  Theobald, ^-^^  the  known 
mosquito-carriers  of  the  worm  are  the  Cnlcx  fatigans,  Mansonia 
uniformis,  M.  pseudotitillans,  Pyretophorns  costaiis,  Myzomia 
rossi,  MyaorhyncJius  nigcrrimus,  M.  minntus,  Cellia  albimana, 
Stegomyia  psendoscuteUaris.  According  to  Bahr,!-*^^  the  worm  is 
capable  of  development  in  the  Ciilc.v  faitgaiis.  but  the  favorite 
intermediary  in  the  Fiji  Islands  is  the  Stegomyia  psciidosatfcl- 
laris.  The  Culex  jcpsoni  may  also  be  involved.  It  is  not  under- 
stood why  the  filariae  will  not  go  on  to  full  development  in  the 
different  mosquitoes.    The  filaria  develops  in  the  thoracic  muscles 


384  TROPICAL   DISEASES. 

of  the  mosquito  and  then  passes  to  the  salivary  system  and  is  in- 
jected in  the  same  way  as  the  malarial  parasite.  If  placed  on  the 
skin,  however,  it  may  work  its  own  way  into^  the  body,  similar  to 
that  of  the  ancylostoma  embryo.  After  the  organism  once  pene- 
trates the  skin  its  further  history  is  not  known  until  it  reaches 
the  adult  condition.  A  male  and  a  female  adult  are  generally 
found  lying  together.  Females  usually  predominate  in  numbers. 
Dead  and  calcified  worms  have  been  found  in  the  lymphatic 
glands,  testes,  epididymis,  spermatic  cord,  and  tunica  vaginalis. 
In  these  locations  the  female  produces  the  microfilariae  which  pass 
through  the  lymphatic  glands  and  thoracic  duct  into  the  blood- 
stream, in  which  they  are  usually  found  at  night,  and  only  under 
rare  conditions  in  the  daytime.  Bahr,  in  the  Fiji  Islands, 
showed  that  in  that  country  this  nocturnal  periodicity  was  not 
maintained.  He  found  them  constantly  in  night  and  day  blood. 
The  adults  lying  in  the  lymph-channels  may  cause  obstruction  to 
the  lymph,  and  this  produces  varices  and  inflammation  of  the 
glands,  which  may  result  in  the  extravasation  of  lymph  or  chyle. 
It  may  be  said  that,  in  regions  in  which  there  is  no  filariasis, 
elephantiasis  is  very  rare,  and  it  is  doubtful  whether  the  few 
cases  that  are  found  are  contracted  in  those  communities.  Adult 
filarise  are  sometimes  found  in  the  tissues  removed  during  opera- 
tions for  elephantiasis.  The  disease  elephantiasis  is  probably  pro- 
duced by  the  attacks  of  lymphangitis  which  result  in  blocking  the 
lymph-channels.  It  has  been  alleged  that  bacterial  infection 
may  be  responsible  for  these  inflammations,  and  Dufogere  has 
described  a  diplococcus  which  he  believes  is  responsible.  The 
probable  cause  of  elephantiasis  in  the  tropics  is  the  Filaria  han- 
crofti,  although  it  is  quite  possible  that  other  filarise  may  be 
concerned. 

It  is  generally  held  that  unless  the  adult  worms  lie  in  a  posi- 
tion to  obstruct  the  flow  of  lymph,  or  that  there  is  injury  to  the 
adult  female  which  causes  abortion  and  liberation  of  eggs  which, 
owing  to  their  oval  shape,  may  block  the  channels  of  the  smaller 
lymph-vessels,  there  are  no  pathologic  effects.  The  fully  devel- 
oped microfilariae  which  circulate  in  the  blood  apparently  haA^e  no 
pathogenic  properties.  Two  types  of  filarial  disease  may  result 
when  filariasis  causes  blocking  of  the  lymph-trunks,  namely,  one 
characterized  by  varicosity  of  the  lymphatics,  and  the  other  by 
edema.    The  manner  in  which  the  filariae  cause  disturbance  can- 


FILARIASIS.  385 

not  be  stated  with  certainty.  It  seems  likely  that  one  or  more 
worms  may  at  times  obstruct  the  thoracic  duct  and  act  as  an 
embolus  or  be  responsible  for  the  production  of  a  thrombus.  The 
worm  may  also  give  rise  to  inflammatory  thickening  of  the  walls 
of  the  lymph-vessel  which  results  in  obstruction  from  the  result- 
ing stenosis  or  thrombosis.  The  general  result  is  a  blocking  of 
the  lymphatic  areas  drained  by  the  implicated  vessels,  with  a 
resulting  varicosity  or  edema,  or  both. 

In  lymphatic  varix  a  compensatory  lymphatic  circulation  is 
soon  established,  but  naturally  before  this  can  be  effected  a  rise  of 
lymph-pressure  and  dilution  of  the  lymphatics  in  the  implicated 
area  must  take  place,  and  it  is  this  condition  that  results  in 
lymphatic  varix  of  different  degrees.  When  the  thoracic  duct  is 
obstructed  a  retrograde  circulation  must  take  place,  and  the  fluid 
is  forced  in  a  backward  direction  to  the  abdominal  and  pelvic 
lymphatics.  As  a  result  of  this  action  the  thoracic  duct  up  to  the 
seat  of  the  obstruction  becomes  enormously  dilated,  sometimes 
to  1^  centimeters  (^  in.)  in  diameter.  Tbis  often  leads  to 
the  formation  of  enormous  varix,  which  may  be  25  centimeters 
(9.84  in.)  or  more  in  diameter,  5  to  15  centimeters  (1.96  to  5.9 
in.)  in  thickness,  and  conceal  the  kidneys,  the  bladder,  and  sper- 
matic cords.  A  white  or  pinkish  fluid  exudes  when  this  mass  is 
pricked.  If  the  obstruction  is  below  the  lacteals  the  fluid  is  clear 
like  ordinary  lymph.  When  the  varix  affects  the  integuments  of 
the  scrotum,  a  condition  called  lymph-scrotum  results.  When 
the  tunica  vaginalis  ruptures,  for  instance,  there  is  chylous  dropsy 
of  that  sac,  or  chylocele.  It  will  be  readily  appreciated  that  a 
number  of  different  lesions  depending  upon  the  site  of  the  obstruc- 
tion may  result. 

When  filarial  disease  is  associated  with  lymphatic  varix, 
microfilarige  can  generally  be  found  in  the  circulating  blood,  as 
well  as  in  the  contents  of  the  dilated  vessels.  It  is  only  in  cases 
of  long  standing  that  microfilariae  are  absent  at  times.  Bahri"*^ 
and  Mansoni-^i  both  state  that  they  have  observed  cases  in 
which  the  microfilariae  gradually  disappear.  Disappearance  is 
attributed  to  the  death  of  the  parent  parasites.  It  is  not 
always  possible  at  autopsy  to  find  the  adult  worm,  and  at  no 
time  have  there  been  any  considerable  numbers  found. 

Sometimes  the  blocking  is  due  to  a  coiled  mass  of  worms. 
Youngi'*-  found  six  females  and  one  male  in  a  mass.     The 

25 


386  TROPICAL   DISEASES. 

obstruction  in  the  lymph-channels  may  be  due  to  the  inflammatory 
changes  caused  by  the  constant  irritation  of  worms  or  their 
products.  Inflammatory  tissue  may  become  organized,  and  thus 
the  blocking  would  continue  even  after  the  adult  worm  had  been 
eliminated.  Bahr^^^  believes  that  the  periodic  discharge  of  the 
microfilariae  may  be  a  factor  in  the  cause  of  lymphangitis,  orchitis 
and  funiculitis.  In  elephantiasis  arabum  the  microfilarise  usually 
are  not  found  in  the  blood.  In  cases  in  which  microfilarise  are 
found  they  are  probably  traceable  to^  a  fresh  infection  by  the 
mosquitO'.  The  consensus  of  opinion  appears  tO'  be  that  elephan- 
tiasis arises  by  damage  to  the  female  worm,  which  causes  her  to 
produce  immature  embryos.  These  cause  blocking  of  the  lymph- 
channels,  but  elephantiasis  will  not  result  unless  there  is  infection 
with  microbes  in  the  blocked  area.  Mechanical  blocking  alone 
may  cause  disturbances  like  lymph-scrotum,  but  not  elephantiasis. 
The  latter  condition  sometimes  follows  operations  for  the  removal 
of  edematous  masses  like  lymph-scrotum. 

The  miniature  tgg  is  50  microns  in  length  by  34  in  breadth, 
while  the  fully  developed  microfilaria  is  250  to  300  microns  in 
length  and  7  to  8  in  breadth. 

The  lymphatic  vessels  in  the  areas  involved  will  be  found 
enlarged  and  inflamed,  and  abscesses  of  varying  size  may  con- 
tain dead  worms  or  the  debris.  The  worms  are  often  calcified 
by  the  deposition  of  lamellar  plates  of  calcium  carbonate.  Some 
of  these  abscesses  on  incision  contain  material  similar  in  appear- 
ance and  consistency  to  apple-butter.  This  substance  is  found  to 
consist  largely  of  eosinophile  cells.  Abscesses  are  most  frequently 
found  on  the  lower  extremities.  The  seats  of  election  are  in  the 
gastrocnemius  near  the  condyles  and  Scarpa's  triangle.  They  are 
probably  due  to  necrosis  caused  by  the  pressure  of  the  worms. 
The  vessel-walls  undergo  various  pathologic  changes.  In  some 
there  is  proliferation  of  the  endothelium-  and  invasion  of  the 
vessel-wall  with  fibrous  tissue.  The  adult  worm  is  often  found 
in  inflammatory  masses  adhering  to  the  skin  in  various  parts  of 
the  body.    A  favorite  seat  is  just  below  the  supraorbital  region. 

A  lymphatic  varix  generally  forms  part  of  a  larger  dilatation 
of  the  pelvic  lymph-vessels  and  glands.  The  glands  are  fre- 
quently perforated  with  dilated  channels,  and  the  vessels  leading 
to  them  are  also'  enormously  enlarged  and  thickened.  On  section 
the  glands  may  present  a  sieve-like  appearance.    In  chylous  extra- 


FiLARlASiS.  387 

vasations  the  thoracic  duct  is  frequently  found  impervious,  and 
the  lacteals,  in  the  lumbar,  pelvic,  and  pudendal  regions  are  always 
enormously  thickened.  In  cases  in  which  there  has  been  chyluria 
it  is  sometimes  possible  to  trace  the  openings  of  the  chylous 
vessels  into  the  bladder. 

CLINICAL    ENTITIES. 

The  various  clinical  entities  which  may  be  caused  by  filarial 
mfections  will  be  taken  up  in  alphabetical  order. 

Abscess.  Many  writers  on  tropical  diseases  have  drawn 
attention  to  the  frequency  with  which  filarial  abscesses  are  found 
in  various  parts  of  the  body.  At  times  the  parent  worm  dies  of 
unknown  causes.  As  a  rule,  the  dead  body  of  sucn  adults  is 
absorbed  just  as  any  absorbable  foreign  body  in  the  human 
organism  is  likely  to  be.  At  times  the  dead  worm  acts  as  an 
irritant,  and  causes  an  abscess,  in  the  contents  of  which  frag- 
ments of  the  adult  filaria  may  be  found.  These  abscesses 
frequently  open  spontaneously,  or  they  may  be  opened  by 
surgical  means,  and  usually  heal  without  further  trouble.  If 
they  should  form  in  the  thorax  or  peritoneal  cavit}^  serious 
consequences,  and  often  death,  may  result.  Manson  is  of  the 
opinion  that  in  certain  instances  abscesses  may  form  inde- 
pendently of  the  death  of  the  parasite.  That  is,  for  instance, 
in  the  varicose  glands,  in  lymph-scrotum,  and  in  elephantiasis. 
The  direct  connection  of  abscesses  with  filarial  disease  is  fre- 
quently overlooked.  The  exciting  cause  is  generally  due  to 
the  death  of  the  adult  worm  which  causes  necrosis  due  to 
pressure  in  cutting  off  the  blood-supply,  and  thus  making 
such  tissues  susceptible  to  infection  by  ordinary  pus  organ- 
isms. The  material  in  the  abscess  is,  as  a  rule,  very  charac- 
teristic, resembling  apple-butter. 

Chyluria.  Chyluria  is  a  name  given  to  that  condition 
which  exists  when  chyle  is  passed  with  the  urine.  It  is  due 
to  the  rupture  of  a  chyle  lymphatic  into  the  bladder  or 
urinary  tract.  The  rupture  is  usually  caused  by  filarial  ob- 
struction in  the  thoracic  duct,  this  causing  pressure  symptoms 
in  the  weaker  lymph-channels  farther  down.  The  onset  of  the 
disease  is  usually  sudden,  and  generally  accompanied  by  pain 
in  the  back,  and  by  aching  sensations  about  the  pelvis  and 
groins.     These  symptoms  are  probably  due  to  the  great  dis- 


388  TROPICAL   DISEASES. 

tention  previous  to  the  rupture  of  the  lymph-vessel.  As  a 
rule,  considerable  amelioration  of  the  pain  occurs  after  the 
rupture  actually  takes  place.  Soon  afterward  the  patient 
notices  that  he  is  passing  milky  urine,  which  may  be  color- 
less, or  range  in  tint  from  pink  or  even  red.  Sometimes  it  is 
quite  white  in  the  morning,  and^  reddish  in  color  later  in  the 
day.  The  urine  is  much  influenced  by  the  kind  of  food  taken, 
and  the  intervals  at  which  it  is  taken.  At  times  there  is  a 
temporary  cessation  of  chyluria,  probably  due  to  a  temporary 
closing  of  the  lymph-vessel. 

Chylous  Urine.  Retention  of  urine,  which  frequently 
occurs,  is  due  to  coagulation  in  the  bladder.  As  a  rule,  it  is 
quite  painful,  but  does  not  persist  more  than  a  few  hours, 
after  which  worm-like  clots  are  passed.  On  standing,  a 
cream-like  substance  resembling  fat  accumulates  on  the  sur- 
face. Fat-globules  are  seldom  found  on  microscopic  exami- 
nation. Microfilarise,  white  and  red  cells,  and  crystals  of  cal- 
cium oxalate  may  be  seen.  The  specific  gravity  varies  from 
1015  to  1020.  The  reaction  is  usually  acid.  If  the  urine  is 
treated  with  ether  and  the  fat-like  substance  removed,  it  will 
be  found  to  vary  from  ^  to  3^  per  cent.  After  the  removal 
of  the  fat,  tests  for  albumin  usually  show  it  to  be  present. 
When  the  quantity  of  fat  is  very  small  the  condition  is  often 
referred  to  as  lymphuria,  and  if  blood  is  present  it  is  referred 
to  as  hematolymphuria.  There  may  be  various  combinations 
of  these  different  urines  at  different  times,  Chyluria  is  not 
directly  dangerous  to  life,  but  if  it  persists  over  a  long  period 
there  may  be  pronounced  anemia,  depression  and  debility. 
As  a  rule,  the  patient,  under  these  circumstances,  becomes 
incapacitated  for  active  vigorous  life.  Chyluria  frequently 
occurs  after  childbirth.  The  disturbance  of  the  pelvic  lym- 
phatics due  to  the  muscular  efforts  during  labor  probably 
causes  rupture  of  the  lymphatics.  In  men  violent  exercise, 
particularly  that  which  brings  the  abdominal  muscles  into 
play,  as,  for  instance,  hauling  a  rope,  or  leaping,  also  brings 
on  at  times  attacks  of  chyluria  in  those  who  are  affected  with 
filaria. 

Treatment.  Various  forms  of  treatment  have  been  advo- 
cated, but  none  of  them  can  be  said  to  be  very  satisfactory. 
Disappearance  of  chyle  is  no  doubt  sometimes  attributed  to 


FILARIASIS.  389 

drugs  which  happen  to  be  given  at  times  when  the  vessels 
would  have  closed  themselves  without  treatment.  A  favorite 
treatment  is  to  place  the  patient  in  bed,  elevate  the  pelvis, 
and  restrict  the  amount  of  food  and  liquid.  A  few  days'  treat- 
ment along  these  lines  often  results  in  a  temporary  cessation 
of  the  chyluria.  Gallic  acid  in  large  doses,  benzoic  acid, 
methylene  blue,  tincture  of  the  chlorid  of  iron,  a  concoction 
of  Mangrove  bark,  chromic  acid,  glycerin,  and  ichythol  may 
be  given.  It  would  seem  desirable  to  try  syrup  of  ipecac  in 
]/!-  to  1-  teaspoonful  (2  to  4  mils)  doses.  Some  cases  may 
lend  themselves  to  operative  relief,  but  in  general  this  method 
of  treatment  is  not  to  be  commended. 

Chylous  Dropsies.  There  may  be  chylous  dropsy  into 
various  regions.  The  seats  of  election  are  usually  the  tunica 
vaginalis  and  the  peritoneum.  In  chylous  tunica  vaginalis 
there  is  a  filling"  up  of  the  tissues  with  an  opaque  fluid  which, 
on  tapping,  is  found  to  be  chylous,  and  may  contain  micro- 
filariae. Sometimes  this  condition  is  preceded  by  an  attack  of 
fever  and  orchitis.  There  may  be  a  rupture  of  lymph-vessels 
directly  into  the  peritoneal  cavity.  All  of  the  foregoing  con- 
ditions, however,  except  that  of  chyluria,  are  apparently  rare. 
The  treatment  is  the  same  as  that  for  chyluria. 

Lymph  Scrotum.  The  scrotum  may  undergo  various  de- 
grees of  enlargement.  A  careful  palpation  will  reveal  a  num- 
ber of  varices,  and  when  pricked  with  a  pin  they  discharge 
large  quantities  of  milky  fluid.  The  vessels  are  filled  with 
chyle.  Frequently  when  filled  with  lymph  the  fluid  is  straw- 
like in  color.  Some  of  these  punctures  flow  until  200  to  250 
mils  (6.6  to  8.3  fo)  of  fluid  have  escaped.  Such  punctures 
often  run  for  many  hours,  much  to  the  annoyance  of  the 
patient  by  soiling  the  clothing  and  by  physical  exhaustion. 
Microfilarise  can  usually  be  detected  on  microscopic  exami- 
nation in  such  fluid.  This  condition  usually  precedes  true 
elephantiasis. 

Treatment.  The  treatment  is  purely  symptomatic.  It 
should  consist  of  mechanical  devices  for  suspending  the  scro- 
tum, and  the  use  of  powder  to  prevent  friction.  Surgical 
intervention  is  at  times  indicated,  and  consists  in  the  excision 
of  the  diseased  tissue.  Great  care  should  be  exercised  to  push 
the   testicles   well   out  of   the   way  during   such   operations. 


390  TROPICAL   DISEASES. 

Most  rigid  antiseptic  precautions  are  indicated,  owing  to  the 
likelihood  of  infection.  When  the  operation  is  done  under 
good  conditions,  the  wound  usually  heals  rapidly  by  first 
intention. 

Chylous  and  Lymph  Diarrhea.  Just  as  there  may  be 
microfilaria,  it  is  possible  for  some  of  the  lacteals  or  lymph- 
vessels  to  establish  a  connection  with  the  intestinal  tract,  and 
chyle  or  lymph,  under  such  circumstances,  may  be  found  in 
the  intestinal  discharges.  This  condition,  however,  is  very 
rare. 

Other  Forms  of  Filarial  Disease.  From  the  foregoing 
description  of  the  pathology  of  filarial  disease,  it  will  be 
apparent  that  blocking  of  the  lymph-channels  may  give  rise 
to  lesions  in  many  parts  of  the  body.  The  location  of  varices 
may  simulate  tumors  of  various  kinds.  Large  masses  are  fre- 
quently found  in  dififerent  parts  of  the  abdominal  cavity. 
Sometimes  their  true  nature  is  not  discovered  until  at  the 
time  of  the  operation.  Enlargement  of  the  glands  of  the  groin 
often  resembles  hernia.  At  times  there  is  invasion  of  the  tes- 
ticle with  symptoms  of  orchitis.  Hydrocele  also  occurs  fre- 
quently. 

Treatment.  No  specific  treatment  is  available.  Unless 
there  is  discomfort  or  mechanical  interference  with  physical 
freedom,  varices  had  better  be  left  alone.  After  all,  they 
carry  on  a  collateral  circulation  which  may  be  of  service. 

FILARIAL    LYMPHANGITIS. 

Filarial  lymphangitis  is  an  inflammation  of  the  lymph-ves- 
sels and  glands  which  resembles  elephantiasis,  but  in  which 
the  filarise  cannot  be  demonstrated.  Elephantoid  disease  or 
elephantoid  fever  is  another  term  for  the  afi^ection. 

Inflammation  of  the  lymph-glands  and  vessels  occurs  in 
all  types  of  filarial  lymphangitis,  and  is  a  preliminary  condi- 
tion to  elephantiasis,  lymph-scrotum,  and  similar  manifesta- 
tions. At  the  beginning  of  an  attack  there  is  usually  painful 
cord-like  swelling  of  the  lymphatic  trunks  and  associated 
glands.  The  attack  usually  begins  with  a  rise  of  tempera- 
ture, varying  from  38.5°  to  40°  C.  (101°  to  104°  F.),  often 
accompanied  by  vomiting  and  headache.     At  times  there  is 


ELEPHANTIASIS.  391 

only  a  red  edematous  area  of  the  skin,  and  the  glands  are  not 
inflamed  or  painful.  In  the  course  of  a  few  days  the  tem- 
perature usually  drops  to  normal,  but  the  erysipelatous  rash 
persists  for  a  number  of  additional  days.  The  attack  usually 
ends  with  profuse  sweating-.  The  swelling  gradually  sub- 
sides, but  never  quite  reaches  normal.  Sometimes  the  ten- 
sion in  the  inflamed  tissues  relieves  itself  by  discharge.  If 
there  is  an  extensive  abdominal  varix,  for  instance,  there  may 
be  symptoms  resembling  peritonitis,  and  the  case  may  end  in 
death.  The  attacks  recur  at  varying  intervals,  and  with  the 
gradual  increase  of  tissue  a  condition  similar  to  elephantiasis 
finally  results.  In  Manila  the  disease  was  of  frequent  occur- 
rence, even  among  the  better  classes.  Among  an  American 
population  of  several  thousand,  6  cases  are  known  to  have 
occurred,  but  in  none  of  them  could  filarise  be  demonstrated. 

The  true  nature  of  the  disease  is  best  shown  by  the 
repeated  attacks  which  occur  at  intervals  of  weeks,  months, 
or  years.  The  redness  and  swelling  caused  by  the  stings  of 
certain  insects  may  be  mistaken  for  a  preliminary  attack.  In 
stings  it  is  usually  possible  to  find  the  primary  lesion.  Some- 
times, owing  to  the  chills  and  the  profuse  sweating,  the  con- 
dition is  mistaken  for  malarial  fever,  but  blood  examination 
would  show  malarial  parasites.  The  erysipelatous  rash  may 
also  be  mistaken  for  true  erysipelas,  but  the  long  febrile 
period  of  erysipelas  will  soon  serve  to  distinguish  it. 

Treatment.  During  the  attack,  rest  with  elevation  of  the 
affected  part,  cold  compresses,  or  hot  fomentations,  may 
be  used;  ^-grain  (0.01  Gm.)  doses  of  calomel  at  hourly 
intervals,  followed  by  large  doses  of  magnesium  sulphate 
as  soon  as  the  calomel  acts,  should  invariably  precede  other 
medication.  Opium  in  suitable  form  may  be  given,  to  relieve 
the  pain. 

ELEPHANTIASIS. 

Elephantiasis  is  a  hypertrophy  of  the  tissues  under  the 
skin  in  areas  of  the  body  affected  by  lymph-stasis,  resulting 
in  enormous  enlargement  of  the  legs,  arms,  or  other  parts  of 
the  body,  and  is  by  far  the  most  striking,  as  well  as  probably 
the  most  frequent,  manifestation  of  filarial  infection. 


392 


TROPICAL  DISEASES. 


Of  the  numerous  synonyms  for  this  disease  the  following 
are  in  vogue :  Cochin  leg,  Barbados  leg,  elephantiasis  arabum, 
elephant  leg,  hypersarcosis,  glandular  disease,  and  Phlegma- 
sia Malabarica. 

Elephantiasis  is  found  in  the  legs,  the  scrotum,  the  vulva, 
the  arms,  the  breast,  and  rarely  in  other  regions.  It  occurs 
wherever  filarial  disease  is  present,  and  it  is  usually  not 
found  in  areas  in  which  filarise  are  absent.  At  times  cases 
of  elephantiasis  have  been  reported  in  filaria-free  areas,  but 
they  were  only  isolated  cases,  and  the  infection  was  probably 


Fig.  16. — Elephantiasis  of  the  lower  extremities.    Front  view. 
(Author's  case.) 

contracted  in  endemic  areas.  Bahr^^*  found  that  in  the  Fiji 
Islands  3.56  per  cent,  of  the  population  examined  were 
afflicted  with  elephantiasis,  and  that  52.5  per  cent,  of  the 
entire  population  showed  evidence  of  filarial  disease  in  some 
form.  It  prevails  extensively  in  nearly  all  the  islands  of  the 
South  Pacific,  the  West  Indies,  the  tropical  Americas,  tropical 
Africa,  and  tropical  Asia.  In  Samoa  it  is  a  veritable  scourge, 
anid  probably  affects  a  larger  percentage  of  the  population 
|;han  in  the  Fiji  Islands,  although  there  are  no  reliable  data 
available  as  to  the  exact  extent  of  its  prevalence. 

Mansoni45  states  that  in  "95  per  cent,  of  the  cases  the 
lower  extremities — either  one  or  both — alone,  or  in  combina- 
tion with  the  scrotum  or  arms;  are  the  seat  of  the  disease. 
The  foot  and  ankle  only,  or  the  foot  and  leg,  or  the  foot,  leg 


ELEPHANTIASIS. 


393 


and  thigh,  may  each  or  all,  be  involved."  The  arms  are  sel- 
dom involved,  and  still  more  rarely  the  mamma,  vulva,  and 
circumscribed  portions  of  the  limbs,  trunk  or  neck. 

The  disease,  regardless  of  the  area  which  is  affected,  com- 
mences with  l3^mphangitis,  and  soon  results  in  dermatitis  and 
in  inflammation  of  the  deeper  cellular  tissue.  The  symptoms 
of  an  acute  attack  are  the  same  as  those  described  under 
filarial  lymphangitis,  including  the  erysipelatous  rash.  These 
processes  are  always  accompanied  by  fever.  The  fever  may 
last  for  from  several  days  to  several  weeks.    After  subsidence 


Fig.  17. — Same  patient  as  Fig.  16.     Side  view.     (Author's  case.) 

of  the  acute  symptoms  the  skin  and  subcutaneous  fascia  of 
the  affected  area  do  not  quite  return  to  their  normal  propor- 
tions. Some  exudate  remains  unabsorbed,  and  a  certain 
amount  of  permanent  thickening  remains.  Recurrences  of 
the  foregoing  process  may  take  place  at  intervals  of  several 
weeks  or  a  month,  or  even  six  months  or  more  may  elapse 
before  another  acute  attack  occurs.  Each  time  a  little  more 
bulk  is  added  to  the  affected  areas,  and  the  part  in  conse- 
quence steadily  increases  in  size.  In  this  way  there  is  grad- 
ually built  up  an  enormous  leg,  or  arm,  or  other  anatomic 
unit.  In  a  few  cases  there  are  no  further  acute  attacks,  and 
the  disease  remains  stationary.  After  one  or  two  attacks  the 
skin  over  the  affected  area  becomes  rough  and  coarse.  The 
papilla  and  glands  may  either  be  hypertrophied  or  atrophied. 
The    hair  becomes   coarse,    and   the    nails   rough,   thick   and 


394  TROPICAL   DISEASES. 

deformed,  no  doubt  because  of  nutritional  disturbances. 
When  extensive  swelling  occurs  over  the  joints  there  is  very 
often  considerable  interference  with  movement.  The  swell- 
ing, as  a  rule,  is  hard  and  dense,  and  only  pits  slightly  on 
pressure. 

The  dorsum  of  the  foot  commonly  becomes  swollen  and 
edematous.  The  debris  of  the  desquamating  epithelium,  with 
the  excretions  of  the  skin,  are  liable  to  accumulate,  and  to 
give  rise  to  foul-smelling  discharges,  and  at  times  ulcers  may 
form.  Some  cases  of  elephantiasis  may  occur  without  there 
having  been  any  attack  of  fever  observed.  The  muscles, 
nerves  or  bones  are  not  necessarily  diseased,  although  at 
times  degenerative  changes  or  atrophy  may  occur  from 
pressure. 

Elephantiasis  of  the  Legs.  As  a  rule,  elephantiasis  of  the 
lower  extremity  is  usually  confined  to  the  section  below  the 
knee.  However,  elephantiasis  of  the  thigh  is  sufficiently 
common.  The  size  of  the  leg-  is  sometimes  enormous,  and 
fully  as  large  as  that  of  an  elephant's  leg,  and  it  is  this  symp- 
tom that  gave  the  disease  its  name.  There  is  always  great 
disturbance  of  the  dermal  appendages.  The  skin  becomes 
rough,  the  hairs  coarse,  the  nails  thickened  and  deformed. 
Ulcers  are  frequently  encountered,  and  may  be  located  in  any 
area.  They  often  follow  slight  injuries,  and,  as  a  rule,  are 
persistent  and  do  not  respond  readily  to  treatment.  Briefly, 
the  symptoms,  with  few  exceptions,  are  the  same  as  those 
described  under  general  elephantiasis. 

Treatment.  A  satisfactory  method  of  treatment  has  not 
yet  been  evolved.  In  India  operative  treatment,  especially 
the  removal  of  large  masses  of  tissue,  has  been  very  generally 
done.  Fibrolysin  injections  have  been  used  by  Castellani,  and 
at  the  Hamburg  Institute  for  Tropical  Diseases,  Avith  a  fair 
amount  of  success.  The  patient  is  placed  at  rest  in  bed,  and 
2-  to  4-  mil  (32.4  to  64.8  m.)  injections  of  fibrolysin 
(thiosinamin  and  salicylic  acid)  are  given  daily  for  periods 
varying  from  three  to  six  months.  Occasional  intervals  of  a 
few  days  are  allowed  between  treatments.  The  injections  are 
given  with  a  hypodermic  syringe,  deeply  into  the  afl^ected 
parts  or  into  the  gluteal  region.  After  the  injection  the  limbs 
are  tightly  bandaged.    At  Hamburg  it  has  been  customary  to 


ELEPHANTIASIS.  395 

apply  a  rubber  bandage  over  the  cotton  bandage,  in  order  to 
bring  about  even  pressure.  On  account  of  the  extreme  heat 
in  the  tropics  rubber  bandaging  is,  as  a  rule,  very  uncom- 
fortable. It  is  especially  recommended  by  Castellani  in  the 
verrucose  type  of  the  disease.  Massaging  of  the  limb  in 
the  elevated  position  appears  to  be  efficacious.  Surgically, 
numerous  operations  have  been  devised.  IMost  of  these  are 
based  on  the  excision  of  wedge-shaped  strips  of  tissue  of  vary- 
ing lengths.  As  a  rule,  surgical  operation  must  be  preceded 
by  medical  treatments  on  the  lines  given  above,  and  no  opera- 
tion attempted  during  acute  febrile  periods.  Southey's  tubes, 
which  consist  of  a  number  of  small  cannulas,  are  inserted 
under  the  skin,  in  order  to  permit  the  free  discharge  of  fluid. 
Great  reductions  in  the  size  of  the  limb  can  frequently  be 
obtained  by  this  method.  It  is  doubtful,  however,  whether 
any  permanent  decrease  in  the  size  of  the  limbs  can  be 
brought  about.  When  the  limbs  become  of  sufficient  size  to 
prevent  a  patient  from  getting  about  comfortably,  amputa- 
tion may  be  indicated.  Some  patients  are  much  better  off 
with  an  artificial  leg  and  foot  than  with  the  enormous  deform- 
ity and  weight  of  elephantiasis. 

Elephantiasis  of  the  Scrotum.  The  scrotum  may  attain 
enormous  size.  A  weight  of  20  pounds  (9.07  Kg.)  is  cus- 
tomary, and  of  50  pounds  (22.67  Kg.)  is  not  infrequent. 
Manson  states^^^  ii^^^^  i\^q  largest  reported  weight  is  224 
pounds  (101.6  Kg.).  The  onset  of  the  disease  and  its  gen- 
eral progress  is  the  same  as  in  other  parts  of  the  body. 

Treatment.  The  complete  excision  of  all  the  affected  tissue 
of  the  scrotum  probably  produces  more  satisfactorj-  results 
than  the  treatment  of  elephantiasis  in  any  other  part  of  the 
body.  The  greatest  care  is  necessary  to  perform  the  opera- 
tion under  the  most  aseptic  conditions.  Infections  are  very 
likely  to  occur,  and  special  attention  is  required  properly  to 
cleanse  the  diseased  scrotal  areas.  Various  operations  have 
been  described,  for  the  details  of  which  a  textbook  on  surgery 
should  be  consulted. 

Elephantiasis  of  the  Vulva.  This  condition  is  essentially 
the  same  as  that  of  elephantiasis  of  the  scrotum.  The  hyper- 
trophy may  implicate  the  labia  majora  or  the  clitoris.  This 
condition   is  rare.     According  to   Manson, i^*'   vulval   tumors 


396 


TROPICAL   DISEASES. 


may  weigh  from  8  to  10  pounds  (3.62  to  4.53  Kg.),  or  even 
more. 

The  treatment  consists  in  the  surgical  removal  of  the 
tumor. 

Elephantiasis  oi"  the  Breast,  Arm,  Scalp  and  Other  Re- 
gions. Elephantiasis  of  the  breast  is  very  rare.  That  of  the 
arm  is  even  rarer,  and  that  of  the  scalp  is  seldom  seen.  Other 
regions  of  the  body  may  be  affected,  but  only  in  the  very 
rarest  instances. 

The  treatment  is  the  same  as  that  indicated  for  elephan- 
tiasis of  other  regions. 


Fig.  18. — Filaria  nocturna.     {Da  Costa.) 

Filarial  Organisms.  As  a  rule,  the  filarise  can  be  found 
in  the  blood  only  during  the  night  hours.  However,  there 
are  exceptions  to  this  rule.  Bahr,i48  for  instance,  working  in 
the  Fiji  Islands,  found  the  microfilarize  as  readily  during  the 
daytime  as  at  night.  In  a  fresh-blood  specimen  the  Micro- 
filaria bancrofti  appears  as  rfiinute,  transparent,  colorless, 
snake-like  micro-organisms,  which  do  not  change  their  position  on 
the  slide,  although  they  wriggle  about  in  great  activity,  con- 
stantly agitating  and  displacing  the  cellular  elements  of  the 
blood  (see  illustration).  In  the  course  of  a  few  hours  the  move- 
ment ceases.  The  microfilariae  are  long,  slender  and  cylindric. 
One  extremity  is  abruptly  rounded,  and  the  other  gradually 
tapers  to  a  fine  point.  The  filaria  is  about  0.3  millimeters 
(001  in.)  in  length,  and  0.008  to  0.001  (0.0003  to  0.00004  in.) 
in  diameter;  in  other  words^  approximately  the  diameter  of 


ELEPHANTIASIS.  39/ 

a  normal  erythrocyte.  As  a  rule,  they  begin  to  appear  in  the 
peripheral  circulation  during  the  early  evening  hours  and 
increase  in  numljers  until  midnight,  after  which  they  gradually 
decrease.  From  300  to  600  may  be  found  in  a  single  drop  of 
blood.  This  periodicity  may  be  maintained  over  a  period 
of  years.  If  the  subject  sleeps  during  the  day  and  is  awake 
during  the  night  hours,  the  periodicity  is  reversed.  ]\Ianson 
states  that  during  their  temporary  absence  from  the  peripheral 
circulation,  the  microfilarias  could  be  found  during  the  day- 
time in  large  numbers  in  the  larger  arteries  and  in  the  lungs. 
Man  is  the  definitive  host;  the  mosquito  the  intermediary 
host. 

The  adult  worm  is  a  long',  hair-like,  transparent  nematode 
from  7  to  10  centimeters  (2.7  to  3.1  in.)  in  length.  The  male 
and  female  usually  lie  closely  together,  and  are  often  inter- 
twined. The  female  filaria  is  the  larger,  both  in  length  and 
diameter.  In  both  sexes  the  oral  end  is  slightly  tapering. 
The  tail  also  tapers  to  comparatively  small  dimensions,  but 
it  is  bluntly  rounded  off.  The  male  worm  can  be  distin- 
guished by  its  smaller  dimensions  and  its  disposition  to  curl, 
and  also  by  the  tendril-like  tail.  In  some  sections^  especially 
in  Africa,  large  numbers  of  Filaria  perstans  may  be  found. 
Sometimes  they  are  found  in  association  with  the  Filaria  loa 
and  the  bancrofti.  Manson^^^  also  describes  Filaria  demar- 
quayi  and  Filaria  ozsardi. 

Death  seldom  takes  place  primarily  from  filarial  disease. 
At  times,  however,  through  rupture  or  perforation  of  impor- 
tant organs,  as,  for  instance,  the  peritoneum,  secondary  con- 
ditions like  peritonitis  or  other  infections  may  occur  which 
result  in  death.  With  the  exception  of  elephantiasis  of  the 
scrotum,  vulva  and  other  regions  in  which  a  complete  ex- 
cision can  be  made,  the  prospects  for  a  cure  are  not  encour- 
aging, and  seldom  take  place.  In  a  fair  percentage  of  cases 
the  disease  soon  becomes  arrested.  The  only  dithculty  re- 
maining is  the  resulting  deformity. 

To  avoid  mosquito-bites  is  the  most  important  consid- 
eration in  the  prophylaxis.  The  consumption  of  food,  like 
bananas,  for  instance,  upon  which  infected  mosquitoes  have 
fed,  may  be  a  possible,  although  not  a  probable,  source  of 
infection.     As  the   mosquitoes,   which   are   mostlv   concerned 


398  TROPICAL   DISEASES. 

in  the  transmission  of  the  disease,  are  more  or  less  domestic 
in  nature  and  breed  in  artificial  containers  and  drainage 
ditches,  antimosquito  measures,  even  of  a  modest  character, 
may  do  much  to  free  a  community  of  the  type  of  mosquitoes 
responsible  for  the  conveyance  of  filarial  disease.  Minor 
drainage  operations  and  the  oiling  of  stagnant  water  should 
always  be  done  in  the  vicinity  of  habitations  in  regions  in 
which  filarial  infection  is  endemic.  Persons  residing  in  filarial 
countries  should  invariably  sleep  under  mosquito-nets.  This 
is  an  important  protective  measure,  on  account  of  the  fact  that 
the  filaria-carrying  mosquito  usually  flies  only  at  night. 

BIBLIOGRAPHY. 

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6.  Manson:     Brit.    Med.   Jour.,    Dec.   8,    1894;    March    14,   21,   28, 
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7.  8.  Manson:     Tropical  Diseases,  Ed.  4,  p.  20. 

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13,  14,  15,  16.  Reed,  Walter ;  Carroll,  James ;  Agramonte  and  Lazear : 
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17.  Marchoux  and  Simond:    Ann.  d'hyg.  et  de  med..  Colon,  1903. 

18.  Graham :  The  Dengue,  Pathology  and  Propagation,  Jour.  Trop. 
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19.  Ashburn  and  Craig:  Etiology  of  Dengue  Fever,  Philippine  Jour. 
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20.  Bruce:  Micrococcus  of  Malta  Fever,  Practitioner,  London,  1887, 
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System  of  Medicine,  1908,  iii,  17. 

21.  Wright  and  Semple:     Lancet,  1897,  i,  656. 

22.  Reports  of  the  Commission  for  the  Investigation  of  Mediter- 
ranean Fever,  London,  1905-07,  i  to  vii. 

23.  Manson:     Tropical  Diseases,  Ed.  4,  pp.  298,  310. 

24.  Strong:     Philippine  Jour.  Sc,  Manila,  1905. 

25.  Castellani,  Aldo,  and  Chalmers :  Manual  of  Tropical  Medicine, 
Ed.  2,  London,  1913,  pp.  1018,  1026. 

26.  Ibid.,  p.  1021. 


BIBLIOGRAPHY.  399 

27.  Osier:     System  of  Medicine,  1908,  iii,  17. 

28.  Bassett-Smith :    Brit.  Med.  Jour.,  ii,  35. 

29.  Negre    and    Raynaud:  Compt.    rend.    Soc.    de    biol.,    Ixxii,    Nos. 
15,  18  and  24. 

30.  Barber :     Philippine  Jour.  Sc.,  1914,  ix,  1. 

31.  32.  Greig :    Indian  Jour.  Med.  Research,  July,  1914. 

33.  Manson:     Tropical  Diseases,  Ed.  4,  p.  395. 

34.  Schobel :    Philippine  Jour.  Sc,  1915,  x.  2. 

35.  Ashburton :    Medical  Reference  Handbook,  New  York,  1910. 
2>6.  Rogers,  Leonard :    Therapeutic  Gazette,  Nov.  15,  1909. 

Z7.  Scheube:    Die  Krankheiten  der  warmeren  Lander.   1910. 

38.  Eraser  and  Stanton:     Annual  Report,  Federated  Malay  States. 

1911. 

39.  Highet:     Ministry  of  Local  Government  Board,  Bangkok,  1913. 

40.  Schiiffner,  W.:    Miinchen  med.  Wchnschr.,  1913,  No.  12. 

41.  Eijkmann:     Geneesk.  Tijdschr.,   Rotterdam,   1911. 

42.  Shiga:    Report  Kitasato  Institute,  1915. 

43.  Scheube  and  Baelz:     Tr.  Soc.  Trop.  Med.  and  Hyg.,  London, 

1911. 

44.  Scheube:    Die  Krankheiten   der  w^armeren   Lander,   1910. 

45.  Guerrero  :     Revista  Filipina  de  Med.  and  Farmacio,  1916,  vii,  225. 

46.  Vedder:     Beriberi,  New  York,  1914. 

47.  Guerrero  :    Revista  Filipina  de  Med.  and  Farmacio,  1916,  vii,  225. 

48.  Dutton:  Tr.   Epidemiological    Soc,    1905-06,  xxv,    1. 

49.  Stephens  and  Fanthan :    Brit.  Med.  Jour.,  1912,  ii,  1182. 

50.  Ford   and    Dutton:     Liverpool    School    of    Trop.    Med.,    Memoir, 
1903,  xi,  1. 

51.  52.  Castellan!  and    Chalmers:     Manual   of   Tropical    Medicine, 
Ed.  2,  pp.  966-990. 

53.  Navarro:      Reports,    Sleeping    Sickness     Commission     of    the 
Royal  Soc,  1903  and  1908. 

54.  Bruce:     Brit.  Med.  Jour.,  1912,  ii,  1183. 

55.  Castellani  and  Chalmers:  Manual  of  Tropical  Medicine,  Ed. 
2,  pp.  866-67. 

56.  Stephens  and  Fanthan:  Brit.  Med.  Jour.,  1912.  ii.  1182. 

57.  Duke:  Proc  Roy.  Med.  and  Chir.  Soc,  London,  1912,  Ixxxv,  B. 
582,  554-561. 

58.  Guiart,  J.:    Presis  de  parasitologic,  Paris,  1910,  p.  406. 

59.  Castellani  and  Chalmers:  Manual  of  Tropical  Medicine,  Ed.  2, 
p.  1304. 

60.  Stiles :    Am.  Med.,  1902,  iii,  777. 

61.  Boycott,  A.  E.:  Milroy  Lectures  on  Ankylostoma  Infection, 
London,  1911,  p.  58. 

62.  63.  Ashf  ord :    New  York  Med.  Jour.,  1900,  Ixxi,  552. 

64.  Stiles:  Prevalence  and,  Distribution  of  Hookworm  Disease  in 
the  United  States,  Pub.  Health  Rep.,  Hyg.  Bui.,  No.  10,  Washington, 
D.  C,  1903. 


400  TROPICAL   DISEASES. 

65.  Castellani  and  Chalmers:  Manual  of  Tropical  Medicine,  Ed. 
2,  p.  1306. 

66.  Ibid.,  p.  556. 
67;-  Ibid.,  p.  558. 

68.  Barber,  M.  A.:  Memorandum  on  Methods  for  Diagnosing  and 
Treating  Uncinariasis,  1917,  p.  1. 

69.  Schiiffner  and  Vervoort :  Das  oleum  chenopodii  anthelmintici 
gegen  ankj^lostomiosis  im  vergleich  zu  anderen  wurmmitteln,  Tr.  xv,  Inter- 
national Congress  on  Hygiene  and  Demography,  1912,  i,  734-739. 

70.  Breinl:    Personal  Interview,  April,   1916. 

71.  72,  73,  74,  75,  76.  Castellani  and  Chalmers:  Manual  of  Tropical 
Medicine,  Ed.  2,  p.  1363. 

77,  78.  Osier :    Bull.  Johns  Hopkins  Hosp.,  1890,  i,  53. 

79.  Manson:    Tropical  Diseases,  Ed.  4,  p.  1437. 

80.  Walker:     Philippine  Jour.  Sc,  1913,  viii,  4. 

81.  Vedder :    Jour.  Am.  Med.  Assn.,  1914,  Ixii,  501. 

82.  Walker :     Philippine  Jour.  Sc,  1913,  viii,  4. 

83.  84,  85,  86,  87,  88,  89,  90.  Castellani  and  Chalmers:  Manual  of 
Tropical  Medicine,  Ed.  2,  p.  1375. 

91.  Darling  and  Bates:    Proc.  Canal  Zone  Med.  Assn.,  1911,  iii,  56. 

92.  Castellani  and  Chalmers:  Manual  of  Tropical  Medicine,  Ed. 
2,  p.  1391. 

93.  Miyake:    Mitt.  a.  d.  Grenzgeb  d.  Med.  u.  Chir.,  1900,  p.  231. 

94.  Horder:    Quart.  Jour.  Med.,  England,  1910,  iii,  121. 

95.  Proescher:  Internat.  Clin.,  1911,  Ser.  21,  iv,  77;  Blake:  Jour. 
Exper.  Med.,  xxiii,  39;  Tileston,  Wilder:  Jour.  Am.  Med.  Assn.,  1916, 
Ixvi,  995. 

96.  Tileston,  Wilder :    Loc.  cit. 

97.  Blake :    Jour.  Exper.  Med.,  1916,  xxiii,  39-60. 

98.  99.  Schottmiiller :    Dermat.  Wchnschr.,  1914,  Iviii,  77. 

100.  Futaki,  Kengo,  et  al:    Jour.  Exper.  Med.,  1916,  xxiii,  249. 

101.  Hata:    Miinchen.  med.  Wchnschr.,  1912,  lix,  854. 

102.  Leishman  :    Lancet,  1910,  i.  11. 

103.  Ashford:  Proc.  Med.  Soc.  Northern  Dist.  Porto  Rico  Med. 
Assn.,  March  18,  1915. 

104.  Halberkaun:  Arch.   f.   Schiffs-  u.  Tropen-Hyg.,   1916,  xx,  225. 

105.  Lunn:     Proc.  Manila  Med.  Soc,  Jan.  31,  1916. 

106.  Brown  :     Bull.  Johns  Hopkins  Hosp.,  1916,  xxvi,  289. 

107.  Price  and  Rogers :     Brit.  Med.  Jour.,  Feb.  7,  1914. 

108.  Rogers :    Brit.  Med.  Jour.,  1916,  i,  301. 

109.  Brill:  Tr.  International  Cong.  Med.,  London,  1914,  Sec.  vi, 
Med.  Part  2,  pp.  83,  97. 

110.  Plotz  and  Olitsky:    Jour.  Infect.  Dis.,  Chicago,  1915,  xvii,  1-68. 

111.  112,  113,  114.  Castellani  and  Chalmers:  Manual  Tropical  Medi- 
cine, Ed.  2. 

115,  116.  Nicolle,  Anderson,  and  Goldberger:  Bull.  Soc.  de  path, 
exot.,  Paris,  1915,  viii,  160. 


BIBLIOGRAPHY.  401 

117,    118.  Ricketts    and   Wilder,    Anderson    and    Goldberger:     Pub. 
Health  Rep.,  Washington,  D.  C,  Feb.  2,  1912. 

119.  Osier:    System  of  Medicine,  Ed.  8,  p.  353. 

120.  Plotz  and  Olitsky :    Loc.  cit. 

121.  Castellani  and  Chalmers:    Manual  of  Tropical  Medicine,  Ed. 
2,  p.  1030. 

122.  Report  6,  Indian  Plague  Commission,  p.  784. 

123.  Ibid.,  p.  742. 

124.  Creel:    Jour.  Am.  Med.  Assn.,  1911,  Ix,  1527. 

125.  126.  Strong:    Annual  Report,  Bureau  of  Science,  Manila,  1912. 

127.  Simpson :    Treatise  on  Plague,  Cambridge  Univ.  Press,  1905. 

128,  129,  130,  131,  132,  133,  134.  Manson:    Tropical  Diseases,  Ed.  4, 
p.  594. 

135.  Bahr:    Jour.  London  School  Trop.  Med.,  1912,  i,  6. 

136.  Castellani  and   Chalmers:    Manual   Tropical   Medicine,   Ed.   2, 
p.  1124. 

137.  Manson:    Tropical   Diseases,  Ed.  4,  p.   594. 

138.  139,  140.  Bahr :    Loc.  cit. 

141.  Manson  :    Loc.  cit. 

142.  Bahr:    Loc.  cit. 

143.  Castellani  and   Chalmers:     Manual  Tropical   Medicine,   Ed.  2, 
p.  1124. 

144.  Bahr:    Loc.  cit. 

145.  Manson  :    p.  630,  loc.  cit. 

146.  147.  Manson  :    p.  594,  loc.  cit.  ' 

148.  Bahr  :    Loc.  cit. 

149.  Manson  :    p.  646,  loc.  cit. 


26 


The  Intoxications 


HENRY    K.    MOHLER,  M.D., 
Medical  Director,  Jefferson  Hospital,  Philadelphia. 


(403) 


The  Intoxications. 


FOREWORD. 

Under  the  heading-  of  The  Intoxications  the  writer  has 
included  the  management  of  the  various  morbid  conditions 
consequent  to  the  introduction  into  the  human  body  of  cer- 
tain chemical  agents  possessed  of  a  poisonous  action.  Of 
these  mercury,  arsenic,  lead,  phosphorus,  silver,  copper,  zinc, 
and  tin  are  prominent  examples,  and  numerous  fatalities  result 
from  their  influence,  both  when  taken  with  suicidal  intent  and 
in  connection  with  industrial  pursuits. 

The  practising  physician  also  is  not  infrequently  called 
upon  to  treat  poisoning  by  illuminating  gas,  so  that  this  con- 
dition is  described  in  some  detail.  The  same  is  true  of  poison- 
ing by  opium,  alcohol,  and  cocain,  and  here,  in  addition,  the 
medical  adviser  is  concerned,  not  only  with  the  active  emer- 
gency, but  with  the  after-treatment  and  the  important  social 
problems  that  invariably  demand  adjustment. 

Food  poisoning  is  approached  from  the  dual  viewpoint  of 
prevention  and  care  of  the  active  toxemia,  and  this  plan  is 
followed  in  the  consideration  of  thermic  fever  and  heat  ex- 
haustion. 

Aside  from  describing  the  principles  of  treatment  in  vogue 
at  the  present  time,  the  leading  features  of  diagnosis  and 
symptomatology  of  the  various  toxic  states  are  briefly  dealt 
with,  along  with  other  details  of  the  clinical  picture  relating 
mainly  to  topics  such  as  personal  predisposition,  the  physical 
state  of  the  subject,  and  the  disturbances  of  the  several  body 
functions.  A  consistent  attempt  has  been  made  to  furnish  the 
reader  with  a  helpful  working  guide  to  the  treatment  of  the 
commoner  intoxications,  and  to  this  end  theoretic  discussion 
has  been  minimized  and  practical  therapeutic  measures  have 
been  emphasized,  in  so  far  as  the  nature  of  the  condition  in 
question  warranted  this  plan  of  procedure. 

(405) 


406  THE   INTOXICATIONS. 

GENERAL    CONSIDERATIONS. 

Toxicology  is  the  scientific  study  of  poisons,  their  sources, 
properties,, actions,  their  detection  and  the  treatment  thereof. 

Authorities  differ  as  to  the  substances  that  should  be  included 
under  the  term  poison. 

Vaughan  defines  a  poison  as  a  substance  of  definite  chemical 
composition  which,  by  virtue  of  its  constitution  is  capable,  when 
brought  in  contact  with  the  tissues  of  the  body,  of  modifying  the 
cellular  activity  of  one  or  more  organs  in  such  a  way  as  to  impair 
health  or  destroy  life. 

Actions  of  Poisons.  The  modes  of  actions  of  poisons  may 
be  classed  as  local  and  co-nsititutional.  To  the  former  class  belong 
those  poisons  which  only  impair  or  destroy  the  tissues  with  which 
they  come  directly  in  contact ;  and  to  the  latter  group  are  referred 
poisions  in  which  the  symptoms  are  due  to  its  presience  in  the 
blood  and  its  effect  upon  the  various  organs  of  the  body. 

Local  and  constitutional  poisons  affect  the  tissues  with  which 
they  are  in  contact,  and  have  further  action  due  to  absorption, 
e.g.,  arsenic  and  carbolic  acid.  The  ordinary  symptoms  of  pois- 
oning are  due  tO'  absorption,  but  in  order  that  any  substance 
should  give  rise  tO'  these  it  is  necessary  that  it  should  be  taken 
into  the  blood  and  carried  throughout  the  circulation. 

Conditions  Influencing  the  Action  of  Poisons.  The  size  of 
the  dose  taken,  the  method  of  administration,  the  physical  state 
of  the  poison,  ag'e,  habits,  previous  health  and  idiosyncrasy  are 
factors  which  determine  the  wide  difference  in  the  symptoms 
induced  by  poisons  in  different  individuals. 

The  Size  of  the  Dose.  As  a  rule,  the  larger  the  dose  of  the 
poison  taken,  the  severer  are  the  symptoms,  and  the  more  likely 
to  prove  fatal. 

Sometimes  a  large  dose  induces  vomiting  or  purgation,  by 
which  the  poison  is  promptly  expelled  from  the  body,  when  a 
smaller  dose,  not  sufBcient  to  produoe  emesis,  results  in  a  marked 
toxemia. 

If  a  large  quantity  of  arsenic  is  quickly  absorbed,  the  usually 
prominent  gastro-intestinal  symptoms  may  be  wholly  wanting, 
while  the  effect  upon  the  central  nervous  system  predominates. 

When  Yi  ounce  (15  mils)  of  spirits  of  turpentine  is  taken 
it  may  cause  symptoms  referable  to  the  gastro-intestinal  tract  so 


GENERAL   CONSIDERATIONS.  407 

severe  that  the  vomiting  and  diarrhea  may  rid  the  body  promptly 
of  the  turpentine;  on  the  other  hand,  1  dram  (3.75  mils)  of 
spirits  of  turpentine  will  not  cause  sufficient  gastro-intestinal  irri- 
tation to  cause  it  to  be  promptly  eliminated,  but  the  slow  action 
upon  the  kidneys  may  result  in  permanent  injury  thereto. 

The  Method  of  Administration.  Poisoins  can  be  introduced 
into  the  body  in  a  numiber  of  ways.  Any  means  may  be  employed 
by  which  it  reaches  the  general  circulation,  viz.,  by  introduction 
into  the  stomach,  or  rectum,  and  from  absorption  through  the 
lymphatics,  or  subcutaneous  injections. 

Rapidity  of  action  depends  on  the  mode  of  administration.  If 
a  poison  enters  the  body  slowly  the  kidneys  and  other  excre- 
tory organs  very  often  can  dispose  of  it  before  serious  effects 
are  produced.  Rapidity  of  action  largely  determines  the  effect 
of  the  poisons  on  the  tissues ;  nevertheless  the  avenue  by 
which  the  poison  is  introduced  is  likewise  an  important  factor. 

Substances.  Arsenic,  when  injected  subcutaneously,  exerts  a 
marked  local  effect  with  but  slight  constitutional  symptoms;  on 
the  other  hand,  the  same  amourDt  of  arsenic,  given  or  taken  by 
mouth,  produces  graver  results. 

The  Physical  State  of  the  Poison.  Upon  the  physical  state 
of  the  poison  depends  largely  the  question  of  absorption. 

Gases  are  more  rapidly  absorbed  than  liquids,  which  are  in 
turn  more  rapidly  absorbed  than  solids. 

The  fineness  of  the  powder  is  a  determining  factor  in  the 
variation  of  the  effects  of  poisons. 

Thus,  the  finer  the  powder  the  more  rapidly  it  passes  into 
solution,  which  is  essential  if  the  poison  is  to  be  absorbed.  Like- 
wise the  finer  the  powder  the  more  surface  of  poison  is  exposed 
whereby  it  can  exert  its  deleterious  local  action.  The  degree  of 
concentration  influences  the  effect  of  poisons. 

A  mineral  acid  in  concentrated  form  may  destroy  all  tissues 
with  which  it  comes  in  contact,  while  the  same  amount  of  acid 
freely  diluted  with  water  may  be  relatively  harmless. 

Physical  Condition  of  Recipient.  As  a  general  rule,  children 
are  more  susceptible  to  poisons  than  adults.  Children  stand 
relatively  larger  amounts  of  arsenic  and  chloral,  and,  on  the 
other  hand,  bear  opium  badly.  The  aged  are  more  readily 
poisoned  than  those  in  middle  life, 


408  THE   INTOXICATIONS. 

The  previous  poor  state  of  the  individuals'  health  renders 
them  more  Hable  to  the  effects  of  poison.  The  exceptions  to  this 
general  statement  are  those  suffering  from  colic,  peritonitis,  and 
delirium  tremens,  who  display  a  marked  tolerance  for  opiates. 

A  person  who  is  co'ntinually  taking  sublethal  doses  of  any 
poisonous  substance  may,  in  so^me  cases,  acquire  a  degree  of  tol- 
erance, and  larger  amounts  are  necessary  tO'  obtain  the  effect  of 
the  drug,  e.g.,  opium.  Other  substances  in,  which  a  tolerance  may 
be  acquired  are  cocain,  tobacco  and  chloral.  Personal  idiosyn- 
cracy  may  account  for  the  untoward  effects  of  full  therapeutic 
doses  of  quinin,  mercury,  bromid,  and  less  frequently,  a  num- 
ber of  other  drugs. 

Classification  of  Poisons.  Any  classification  attempted  must, 
of  necessity,  be  more  or  less  arbitrary,  especially  if  based  upon 
the  physical  action  of  the  poison. 

Poisons  have  been  classified  according  to  their  origin  and 
chemical  co'mposition,  i.e.,  inorganic  and  organic;  and  animal, 
mineral  and  vegetable. 

Taylor  classes  all  poisons  under  two'  heads : 

Irritant. 
Neurotic. 

Irritants.  All  poisons  which  have  an  irritating  and  destruc- 
tive action  upon  the  tissues  with  which  they  come  in  contact,  and, 
when  taken  by  way  of  the  alimientary  tract,  are  followed  by 
greater  or  lesser  amount  of  irritation  and  destruction  of  the 
tissue  of  that  canal  are  classed  as  irritants. 

As  a  result  locally  the  ingestion  of  poisons  is  followed  by 
nausea,  vomiting  and  diarrhea  accompanied  by  blooid. 

Irritants  are  further  subdivided  into  irritants  proper,  and  in- 
clude all  chemicalsi  whose  poisonous  effects  largely,  if  not  entirely, 
depend  upon  their  irritant  and  destructive  action  on  tissues  with 
which  they  come  in  contact.  Stronger  acids  and  alkalies  belong 
to  this  group. 

The  second  class  of  irritants  are  the  specific  irritants  whose 
poisonous  action  depends  not  only  upon  their  irritating  effect,  but 
on  specific  physiological  results  which  follow  the  taking  of  the 
poison.  To'  this  class  belong  such  metals  as  arsenic,  antimony, 
mercury,  copper  and  lead ;  non-metallic  poisons,  as  chlorin, 
bromin,   iodin,   and   phosphorus;  vegetable  irritants  such   as 


GENERAL   CONSIDERATIONS.  409 

oxalic  acid,  tartaric  acid,  croton  oil,  elaterium ;  animal  poisons, 
as  canitharides  and  albumins  developed  during  putrefaction. 

Neurotics.  Under  the  general  heading  of  Neurotic  Poisons 
are  included  a  group  of  poisons  which  act  specially  upon  the 
great  nerve  centers,  the  symptoms  presented  being  those  depend- 
ent upon  their  action  upon  the  brain  and  spinal  cord.  The  symp- 
toms of  this  group  are  drowsiness,  headache,  delirium,  coma, 
convulsions  or  paralysis. 

Subdivisions  of  neurotic  poisons :  cerebral  neurotic,  including 
anesthetics  and  depressants,  spinal  neurotic  or  tetanies,  and  cere- 
brospinal neurotics  or  deliriantsi. 

Symptomatology  of  Poisons.  A  wide  range  of  symptoms  are 
to  be  looked  for  as  the  result  of  poisoning,  and  upon  their  prompt 
recognition  and  association  depends  the  success  of  the  treatment. 

Among  the  symptoms  more  or  less  common  to  poisons  are 
the  following: 

Vomiting  and  Purging.  These  symptoms  suggest  that  nature 
is  endeavoring  to  rid  the  gastro-intestinal  tract  of  irritating  sub- 
stances, and  are,  indeed,  common  in  practically  all  forms  of 
poisoning.  The  prompt  appearance  of  these  symptoms  following 
the  onset  of  poisoning  is  often  life-saving.  The  vomiting  and 
purging  usually  are  present  at  the  same  time,  although  vomiting 
may  occur  independently  of  purging,  for  example,  in  opium 
poisoning.  The  intensity  of  one  or  both  of  these  symptoms 
varies  greatly. 

Tlie  Temperature.  No  great  change  occurs  in  the  tempera- 
ture, but  it  is  not  uncommon  to  find  the  temperature  subnormal, 
seldom  increased  except  in  some  conditions  characterized  by 
tetanoid  convulsions,  e.g.,  strychnin  poisoning.  The  shock  to 
the  system  as  the  result  of  vomiting,  or  pain  produced  by 
passing  a  stomach-tube,  has  caused  the  temperature  to  vary. 
The  increase  in  temperature  is  seldom  more  than  several  de- 
grees, while  in  severe  or  fatal  cases  the  temperature  may  drop 
to  95°  F.  (35°  C). 

The  Pulse.  As  a  general  rule  the  rate  of  the  pulse  in 
cases  of  acute  poisoning  is  increased.  This  condition  is  de- 
pendent upon  the  amount  of  shock  present,  and  the  depressant 
action  the  poison  may  have  on  the  heart  directly  or  through 
the  nerve  mechanism  controlling  the  heart.  Poisons  that  act 
directly  upon  the  respiratory  center  may  prove  fatal  without  a 


410  THE   INTOXICATIONS. 

change  in  the  rate  of  pulse,  which  continues  to  beat  some  time 
after  the  respirations  have  ceased. 

Respiration.  Dyspnea  is  the  most  common,  symptom  recog- 
nized' in  cases  of  acute  poisonings,  which  may  be  due  to  mechan- 
ical obstrdction,  as  in  edema  of  the  glottis  from  the  local  action 
of  a  corrosive  poison.  Paralysis  or  spasm  of  the  respiratory 
muscles,  the  fo^nner  observed  in  chronic  lead  poisoning,  and  the 
latter  in  strychnin  poisoning,  accounts  for  dyspnea  and  varia- 
tion in  the  respiratory  rate. 

Cerebral  Symptoms.  These  symptoms,  common  in  many 
other  diseases,  are  likewise  prominent  in  many  of  the  cases  of 
acute  poisonings.  It  is.,  therefore,  important  to  seek  the  cause 
of  this  group  of  sympto^ms. 

Illusions,  hallucinations  and  delusions  may  follow  poisonous 
doses  of  a  number  of  drugs — opium,  chloral,  quinin  and  sali- 
cylic acid.  Convulsions  have  been  noted  in  belladonna  and 
strychnin  poisoning.  In  the  latter  stages  of  many  of  the  pois- 
ons other  than  narcotics,  stupor  and  coma  supervene. 

Vasomotor  Disturbances.  Apparently  the  vasomotor  center  is 
easily  affected  by  poisons,  as  the  result  of  which  changes  in  the 
heart-action  and  respiration  occur.  Variations  noted  in  the  skin 
are  alternate  or  continuous  flushing  and  blanching,  and  frequently 
the  skin  is  cold  or  clammy,  or  dry  and  red. 

Motor  Disturbances.  The  muscular  spasm  and  convulsions  in 
tetanus  and  strychnin  poisons  are  very  prominent  symptoms, 
and  of  diagnostic  import. 

Groups  of  muscles  may.  be  paralyzed,  such  as  the  musculo- 
spiral  palsy  associated  with  plumbism. 

Skin  Lesions.  Many  drugs  produce,  if  taken  over  a  great 
length  of  time,  or  if  a  hypersenisitiveness  is  present,  a  variety  of 
more  or  less  uniform  skin  lesions,  such  as  the  papular  and  acni- 
form  rashes  when  iodids  and  bromids  are  taken;  the  char- 
acteristic rashes  following  the  introduction  into  the  body  of 
belladonna  and  iodoform  in  poisonous  doses.  As  the  result 
of  prolonged  use  of  silver,  a  peculiar  bluish  color  of  the  skin 
is  noted,  due  to  the  subcutaneous  deposit  of  silver  called 
argyria. 

Sensation  /Abnormalities.  The  neuritis  of  chronic  arsenical 
poisoning  is  sufficiently  distinct  to  be  considered  a  factor  in  cases 
of  neuritis  presenting  themselves  for  diagnosis  and  treatment. 


GENERAL   CONSIDERATIONS.  411 

The  variation  in  sensation  associated  with  chronic  cocain 
poisoning  is  of  diagnostic  aid. 

The  Eye.  The  examination  of  the  eyes  is  diagnostic  in 
cases  of  poisoning,  frequently  giving  important  ckies  in  identify- 
ing the  poison.  The  pupil  in  opium  poisoning  is  pin-point,  and, 
just  prior  to  death,  dilates. 

Poisonous  doses  of  santonin  produce  yellow  vision ;  and  in- 
gestion of  wood  alcohol  in  sufficient  quantity  produces  blindness. 

Atropin  produces  dilatation  of  the  pupil,  taken  internally  as 
such,  or  a  belladonna  preparation,  like  a  solution  of  atropin, 
dropped  into  the  eye  will  produce  a  similar  effect. 

Ear.  Quinin  in  very  full  doses  produces  ringing  noises  in 
the  ear;  and  the  buzzing  caused  by  salicylates  or  salicylic  acid 
is  very  characteristic. 

The  Diagnosis  of  Poisoning.  The  detection  of  a  case  O'f 
poisomng  is  not  always  a  simple  task,  especially  if  given  or  taken 
with  criminal  intent.  Accidental  poisonings  are  usually  promptly 
reported  to  physicians,  with  the  diagnosis  very  clear. 

In  every  case  of  suspicious  poisoning,  any  food,  drink  or 
medicine,  vomitus  and  excreta,  should  be  inspected,  and,  if  neces- 
sary, samples  should  be  taken  for  chemical  or  micro'scopical 
examination. 

Vomitus.  The  vomitus  may  show  something  of  value  by  its 
appearance,  odor  and  color,  such  as  the  odor  of  laudanum,  car- 
bolic acid,  or  hydrocyanic  acid,  which  is  characteristic.  Por- 
tions of  the  undissolved  poison  may  be  present  in  the  vomitus. 
as  particles  of  bichlorid  of  mercur}-  tablets.  The  vomitus  in 
phosphorus  poisoning  is  luminous  in  the  dark. 

The  odor  of  the  exhaled  air  may  promptly  suggest  the  variety 
and  presence  of  a  poison. 

The  urine  should  be  obtained,  and  promptly  submitted  to 
examination  in  every  case  of  poisoning. 

Sulphonal  and  trional  in  poisonous  doses,  or  given  over  a 
great  length  of  time,  make  the  color  of  the  urine  a  rich  Bur- 
gundy red.  The  urine  alkalinized  after  santonin  poison  be- 
comes bright  red. 

Iodoform  or  iodin  can  be  detected  in  the  urine  bv  cliemical 
tests. 

Phenol  and  allied  bodies  render  the  urine  a  dark  green  or 
smoky  color,  spoken  of  as  smoky  urine. 


412  THE   INTOXICATIONS. 

Blood,  albumin  and  casts  appear  in  the  urine  as  a  result  of 
irritant  poisons,  as  cantharides,  chlorate  of  potash,  turpentine, 
or  any  substance  that  causes  an  acute  nephritis.  The  urine 
may  have  the  odor  of  violets  after  turpentine  poisoning. 

It  is  likewise  important  to  bear  in  mind  that  not  every  per- 
son found  unconscious  in  a  bedroom,  or  bathroom,  w^ith  bottles 
of  poison  about,  is  necessarily  suffering  from  attempted  suicide 
by  poisoning.  Uremia  or  diabetic  coma  has  thus  been  mis- 
taken for  cases  of  poisoning.  An  examination  of  the  mouth, 
hair,  face,  lips,  and  tongue  may  often  disclose  marks  of  cor- 
rosive poisoning. 

In  cases  of  poisoning  with  suicidal  intention^  the  patient's 
clothes  and  the  immediate  vicinity  about  the  patient  should 
be  searched  for  clues  to  identify  the  poison. 

The  examination  of  the  skin  of  chronic  morphin  and 
cocain  habitues  usually  reveals  the  prick-points  of  hypo- 
dermic needles.  When  poison  is  unsuspectedly  taken  with 
food  or  water,  the  evidence  of  its  occurrence  may  be  furnished 
by  the  fact  that  a  number  of  persons  are  suddenly  seized  at 
about  the  same  time  under  similar  conditions.  The  evidence 
upon  which  a  case  of  poisoning  is  based  will  be,  first,  the 
symptoms  in  a  patient  while  alive ;  second,  the  symptoms  dis- 
covered at  autopsy ;  third,  the  result  of  chemical  analysis ;  and 
fourth,  moral  or  circumstantial  evidence. 

PRINCIPLES    OF    TREATMENT    OF    POISONING. 

1.  Removing  poison  from  the  body. 

2.  Rendering  the  poison  inert  by  forming  a  new  chemical 
compound. 

3.  Neutralizing  the  effect  of  a  poison  by  the  administra- 
tion of  a  drug  having  the  opposite  action. 

4.  Treatment  of  special  symptoms. 

Removing  the  Poison  from  the  Body.  This  may  be  accom- 
plished by  the  use  of  the  stomach-tube ;  by  giving  purgatives 
or  emetics. 

The  stomach-pump  is,  in  the  majority  of  instances,  the 
most  effective  means  we  have  of  removing  poison.  The  use 
of  the  tube  may  be  of  value  even  if  the  drug  is  given  or  taken 


PRINCIPLES    OF   TREATMENT   OF    POISONING.  413 

hypodermically,  as  in  hypodermic  morphin  poisoning  the  drug  is 
eHminated  from  time  to  time  into  the  stomach. 

Following  the  ingestion  of  corrosive  poisons,  because  of 
Spasm  or  great  pain,  or  danger  of  perforation,  the  use  of  the 
stomach-tube  is  contraindicated. 

Simple  warm  water  may  be  used,  but  the  addition  of  per- 
manganate of  potash,  or  tannic  acid  in  the  cases  of  alkaloidal 
poisons,  the  white  of  egg  in  mercury  poisoning,  and  ferric  hy- 
droxid  in  arsenic  poisoning,  greatly  aid  in  antagonizing  the  poi- 
sonous efifects  of  the  drug. 

Emesis.  This  is  frequently  the  first  remedial  measure  applied, 
and  very  effective,  although  not  to  be  preferred  to  the  use  of 
the  stomach-tube  provided  that  facilities  for  both  are  at  hand. 

Domestic  remedies,  and  means  known  to  every  one,  are 
usually  available,  and  can  be  used  until  a  stomach-tube  is 
obtainable.  In  the  case  of  large  particles  of  poisonous  sub- 
stances remaining  in  the  stomach,  the  caliber  of  the  stomach- 
tube  may  not  permit  the  aspiration  of  the  poison,  and  there- 
fore it  may  be  necessary  to  use  emesis. 

Tickling  the  fauces  or  the  post-pharyngeal  wall  usually 
produces  emesis.  Emetics  are  contraindicated  in  corrosive 
poisons.  Emetics  are  often  useless  in  poisoning  by  narcotics, 
or  by  substances  which  diminish  the  sensibilities  of  the 
mucous  membrane  of  the  stomach. 

Emetics  act  locally  upon  the  stomach,  or  centrally  upon  the 
vomiting  centers  of  the  brain. 

The  following  are  emetics  commonly  used  that  act  locally : 

Mustard  and  Water.  A  tablespoonful  (14.1  Gms.)  of  mus- 
tard in  a  glass  of  warm  water. 

Salt  and  Water.  One  or  2  tablespoonfuls  (15  or  30  Gms.) 
may  be  given  in  a  tumbler  of  warm  water. 

Zinc  SulpJiatc.  Twenty  or  30  grains  (1.3  or  2  Gms.)  dis- 
solved in  4  ounces  (120  mils)  of  warm  water  may  be  given,  and 
repeated  if  necessary. 

Ipecac.  In  the  form  of  syrup,  1  or  2  ounces  (30  or  60  mils) 
repeated  if  necessary  in  fifteen  minutes,  for  an  adult,  or  4  to  6 
drams  (15  to  24  mils)  of  the  wine. 

Emetics  acting  centrally  are  of  use  in  cases  of  narcotic- 
poisoning.  The  principal  objection  is  the  great  amount  of  de- 
pression produced  by  them. 


414  THE   INTOXICATIONS. 

Apomorphin,  best  administered  hypodermically,  in  doses  %o 
grain  (0.006  Gm.).  Tartar  emetic  should  not  be  used  because 
of  great  depression  produced. 

Purgations.  A  brisk  purge  is  an  appropriate  means  of  aiding 
in  the  elimination,  and  often  the  saline  may  be  put  in  the 
stomach  through  stomach-tube  while  in  situ.  A  purge  is  par- 
ticularly indicated  when  material  has  passed  from  the  stomach 
into  the  intestines ;  an  enema  given  at  the  time  an  inclination 
of  the  bowels  to  move  is  experienced  is  very  advantageous. 

Poisons  may  be  rendered  inert  by  forming  therefrom  an 
insoluble  compound,  as  in  the  case  of  sulphates,  given  in  lead 
poisoning.  Alkali  poisons  are  neutralized  by  acids  and  z'ice 
versa. 

Solutions  of  permanganate  of  potash  oxidize,  and  thereby 
render  less  poisonous  the  effects  of  alkaloids.  The  albumin- 
ates of  the  metals  are  rather  insoluble,  but  should  not  be 
allowed  to  remain  in  the  stomach  or  intestines,  as  they  are 
absorbed  slowly,  whereupon  symptoms  of  poisoning  reappear. 

Neutralization  of  the  effects  of  a  poison  may  in  a  sense  be 
effected  by  administering  a  drug  having  the  opposite  action. 

No  one  drug  has  exactly  the  opposite  action  of  another,  but 
there  are  drugs  whose  principal  action  is  exactly  the  opposite 
of  that  of  another.  The  action  of  drugs,  while  opposite  in 
effect,  may  not  be  manifest  simultaneously,  one  or  the  other 
acting  slowly. 

Because  a  drug  is  theoretically  antagonistic  does  not  mean 
that  it  is  the  best  antidote ;  and  the  fact  that  it  is  the  best  anti- 
dote is  not  proof  that  the  reverse  is  true. 

A  few  examples  of  the  use  of  drugs  having  antagonistic 
actions  are  noted. 

Atropin  and  physostigmin.  Atropin  in  small  doses  is  an 
excellent  antidote  to  poisoning  by  physostigmin. 

Atropin  and  pilocarpin.  Pilocarpin  forms  a  sound  anti- 
dote to  atropin. 

Morphin  and  atropin.  Atropin  acts  as  an  antidote  by 
neutralizing  the  depressing  action  of  morphin  upon  the  re- 
spiratory center  and  higher  cerebral  centers. 

Strychnin  and  chloral.  Chloral,  which  acts  to  a  certain 
extent  upon  the  spinal  cord,  but  chiefly  on  cerebrum,  is  a  valu- 
able antidote  to  strychnin. 


MERCURIAL   POISONING.  415 

Other  instances  of  antagonism  in  drug  action  are  aconite 
and  digitalis,  and  hydrocyanic  acid  and  chloroform. 

Treatment  of  Special  Symptoms.  This  subject  will  be  treated 
under  the  discussion  of  each  poison. 

MERCURIAL    POISONING. 

Poisoning  by  mercury  manifests  itself  as  the  acute  and  the 
chronic  form.  The  vapor  of  metallic  mercury  is  highly  toxic, 
and  chronic  poisoning  is  a  frequent  occurrence  among  workers 
engaged  in  smelting  ores  contaminated  with  mercury. 

Mercuric  chlorid  owes  its  corrosive  action  to  its  affinity 
for  the  proteins.  The  mercury  is  absorbed  into  the  blood- 
stream as  the  albuminate  if  absorbed  by  skin  or  mucous  mem- 
brane, regardless  of  the  kind  of  salt  of  mercury  taken  or  given. 

Gastro-intestinal  irritation  and  inflammation  are  encoun- 
tered as  the  dominant  pathologic  lesion  in  acute  mercurial 
poisoning.  Various  degrees  of  inflammation  may  be  present, 
and  hemorrhage  may  be  associated  wnth  erosions  of  the 
mucous  membrane,  or  even  perforation  of  the  stomach  or 
intestines.  The  corrosive  action  of  the  bichlorid  of  mercury 
produces  the  effects  that  are  noted  when  acids  or  alkalies  are 
swallowed. 

If  the  poisonous  dose  of  mercury  has  caused  death  in  a  few 
minutes,  histologic  changes  are  not  prominent.  Discoloration 
and  ulcers  of  the  gums  have  been  noted,  and  at  autopsy  fatty 
degeneration  of  the  viscera  is  seen,  especially  in  the  kidneys 
and  in  the  liver.  Often  deposits  of  lime  are  found  in  the  kid- 
neys, due  to  the  fact  that  in  mercurial  poisoning  calcification 
occurs  in  the  renal  epithelium.  The  researches  of  E.  Ludurg 
have  shown  that  the  places  of  predilection  for  the  deposit  of 
mercury  are  the  kidneys,  liver,  and  the  walls  of  large  intestines, 
in  thei  order  named.  Uremia  and  the  lesions  of  neuritis  have 
been  noted. 

The  large  majority  of  cases  of  mercurial  poisoning  are 
caused  by  bichlorid  of  mercury.  The  symptoms  complained 
of  are  a  burning  sensation  in  the  mouth  and  throat,  accom- 
panied by  constriction  due  to  the  local  action  of  the  poison. 

When  the  poison  reaches  the  stomach,  pain  is  com]:)lained 
of,  and  usually  severe  vomiting  follows.    Often  the  vomitus  is 


416  THE   INTOXICATIONS. 

streaked  with  blood.  The  vomiting  is  followed  by  purging, 
and  hemorrhages  from  the  bowels  may  occur. 

Accompanying  these  symptoms  usually  are  the  evidences 
of  collapse;  the  pulse  beco^mes  rapid  and  feeble;  a  cold,  clammy 
skin;  thirst  is  complained  of;  respiration  is  rapid  and  labored; 
and  muscular  cramps  are  not  uncommon.  Death,  preceded  by 
coma  or  convulsions,  may  end  the  scene. 

The.  symptoms  of  mercurial  poisoning  vary  widely.  An 
individual  may  take  a  poisonous  dose  and  not  be  treated 
promptly,  experience  slight  distress  upon  taking  the  poison  by 
mouth  and  swallowing  it,  and  not  until  a  week  or  ten  days 
later  pass  into  coma  and  die,  with  or  without  convulsions;  on 
the  other  hand,  through  violent  vomiting  or  purging,  the  sys- 
tem may  eliminate  the  poison,  and  no  ill  efifects  be  per- 
manently experienced. 

Slight  chronic  mercurial  poisoning,  which  is  not  very  com- 
mon, due  to  too  long  continued  treatment  or  too  large  doses 
of  mercury,  is  manifested  by  salivation,  sore  gums,  foul 
breath,  abdominal  pains,  and  not  uncommonly  diarrhea.  Ne- 
crosis of  the  bones  of  the  jaws  has  been  observed.  Skin  erup- 
tions may  be  noted ;  a  slight  fever  and  headache. 

TREATMENT. 

Tn  an  acute  case  of  mercurial  poisoning,  large  quantities  of 
an  albuminous  substance,  such  as  the  white  of  egg,  should  be 
given  by  mouth.  In  this  manner  the  mercury  unites  with  the 
albumin  and  forms  the  albuminate  of  mercury,  which  is  not  an 
inert  substance,  but  which  should  be  removed  from  the  stom- 
ach by  means  of  the  stomach-tube. 

The  value  of  an  albuminous  substance  is  that  it  lessens  the 
corrosive  action  of  the  mercury,  and  hence  protects  the  mucous 
membrane  of  the  stomach.  Albuminate  of  mercury  is  highly 
poisonous  but  possesses  no  corrosive  action. 

With  the  advance  in  the  knowledge  and  results  of  treat- 
ment, aided  by  the  studies  of  Lewis  and  Rivers,  Lambert  and 
Patterson,  Bellfield  and  others,  the  condition  does  not  appear 
so  hopeless  as  was  prognosticated  in  the  past. 

A  great  deal  of  new  information  has  thrown  light  upon  the 
functional  activities  of  the  kidneys,  as  recorded  by  the  phenol- 
phthalein  test;  estimation  of  the  urea  and  non-protein  nitro- 


MERCURIAL    POISONING.  417 

gen  of  the  blood,  which  in  turn  appHed  to  the  study  of  the  kid- 
neys in  mercurial  poisoning,  furnishes  a  rational  background 
upon  which  to  base  the  character  and  effectiveness  of 
treatment. 

Briefly,  elimination  is  the  factor  essential  to  secure  favor- 
able results,  and  every  effort  is  directed  to  this  end  in  the 
treatment  of  mercurial  poisoning. 

Since  the  excretion  of  mercury  into  the  stomach  and  intes- 
tines, as  well  as  elimination  by  the  sweat-glands,  has  been 
definitely  established,  it  is  important  that  the  stomach  and  in- 
testines be  washed  out  frequently.  Frequent  sweats  induced 
by  hot  packs  are  most  beneficial. 

MacNider  has  shown  that  the  administration  of  alkalies  is 
capable  of  partly  protecting  the  kidneys  from  the  effects  of  the 
salts  of  heavy  metals  like  uranium,  which  leads  to  pronounced 
nephritic  disease,  as  mercury  does. 

The  results  of  the  estimation  of  the  non-protein  nitrogen  of 
the  blood  indicate  the  retention  of  nitrogenous  waste. 

Lewis  and  Rivers  therefore  urge  the  administration  of  car- 
bohydrate in  the  form  of  glucose.  The  glucose  is  supposed 
to  act  in  the  capacity  of  a  protein-sparing  agent. 

Mercurial  stomatitis  is  best  treated  with  a  mouth-wash 
consisting  of  chlorate  of  potash,  7^  grains  (0.5  Gm.)  to  1 
ounce  (30  mils)  of  water. 

The  teeth  should  be  kept  clean  by  the  use  of  an  alkaline 
tooth-powder  or  wash  used  on  a  toothbrush  with  soft  bristles. 

Belladonna  preparation  given  internally  will  lessen  saliva- 
tion, if  very  annoying. 

Astringent  mouth-washes  composed  of  alum  and  tannic 
acid  are  useful. 

Fantus  recommends  the  following  antidotal  treatment : 
immediate  administration  of  a  tablet  composed  of  sodium 
phosphate  0.36  Gm.  (6  gr.)  and  sodium  acetate  0.24  Gm. 
(4  gr.).  If  this  is  not  available,  give  the  following:  sodium 
hypophosphite  100  Gms.  (3  oz.  230  gr.),  water  10  mils  (160  in.), 
and  hydrogen  peroxid  5  mils  (80  m.).  If  the  amount  of 
the  poison  taken  be  known,  ten  times  as  much  of  hypophosphite 
should  be  given  as  poison  was  taken.  As  this  might  require  a 
large  and  possibly  hannful  amount  of  hypophosphite,  it  should 
immediately  be  followed  by  a  copious  lavage  with  a  very  dilute 

27 


418  THE   INTOXICATIONS. 

solution  of  the  antidote.  This  may  be  followed  by  a  safe  dose 
of  the  antidote,  which  is  to  be  retained,  and  which  can  be  re- 
peated every  eight  hours  for  several  days.  This  antidotal  treat- 
ment can  be  combined  with  some  eliminant  treatment  as  suggested 
by  Lambert  and  Patterson. 

Elimination  is  vigorously  sought  after,  and  to  its  attain- 
ment is  attributed  the  success  of  this  mode  of  treatment. 

The  stomach  and  the  colon  are  washed  out  twice  daily 
with  warm  normal  saline  solution.  The  patient  is  placed  on  a 
liquid  diet  consisting  of  8  ounces  (250  mils)  of  milk  every  two 
hours  to  be  alternated  every  two  hours  with  8  ounces  (250 
mils)  of  the  following  mixture : 

Potassium  bitartrate. 

Sugar,  of  each  Sj  (3.9  Gms.). 

Lactose    3iv   (15.6  Gms.) . 

Lemon  juice   f Sj    (3U  mils) . 

Boiled  water  f §xvj    (500  mils) . 

In  addition  to  the  large  amount  of  water  given  by  mouth 
a  solution  of  1  ounce  of  potassium  bitartrate  (31.2  Gms.)  to  a 
pint  (500  mils)  of  water  is  given  continuously  by  rectum. 

Daily  hot  packs  are  given  to  the  patient.  This  treatment 
should  be  continued  and  its  efficiency  measured  by  the  phenol- 
sulphonephthalein  test  until  no  mercury  can  be  detected  in  the 
excretion  fluids. 

ARSENIC    POISONING. 

Arsenic  poiisoning  resembles  coniditions  noted  in  other  dis- 
eases. A  positive  diagnosis  of  arsenical  poisbmng  or  its  exclu- 
sion cannot  be  made  upon  symptoms  alone,  and  the  presence  of 
arsenic  by  chemical  examination  must  be  determined  before  poisi- 
tive  statements  can  be  made. 

Acute  Poisoning.  After  a  poisonous  dose  of  arsenic  has  been 
taken  into  the  body,  symptomis  usually  referable  to  the  gastro-, 
intestinal  tract  generally  appear  within  twO'  hours.  A  sensation 
of  faintness  in  the  epigastriuim  is  not  uncommonly  an  early 
symptom.  This  is  followed  by  retching,  nausea  and  vomiting, 
which  are  present  throughout  the  attack  or  until  death  intervenes. 
The  vomiting  is  accompanied  by  a  sensation  of  burning  and  dry- 
ness in  the  mouth,  throat  and  stomach,  and  a  marked  thirst. 


ARSENIC    POISONING.  419 

After  the  contents  of  the  large  bowel  have  been  expelled  the 
stools  become  more  and  more  choleraic  in  character,  and  are 
designated  as  "rice-water." 

Extreme  prostration  as  the  result  of  continuous  vomiting  and 
purging  ends  in  collapse,  with  pallor,  cold,  clammy  skin,  sunken 
eyes,  rapid-running  pulse,  and  shallow  respiration. 

Unless  promptly  treated,  the  patient  usually  dies  within 
twenty-four  hours,  death'  being  preceded  by  coma  and  convul- 
sions. 

Occasionally,  when  a  poisonous  dose  of  arsenic  has  been 
rapidly  absorbed,  death  may  occur  promptly,  after  a  state  of 
collapse,  with  no  gastro-intestinal  symptoms.  Such  a  condition 
has  been  known  to  occur  when  a  soluble  salt  of  arsenic  has  been 
introduced  intO'  an  empty  stomach. 

The  mortality  in  acute  arsenical  poisoning  varies,  depending 
on  the  promptness  and  efficiency  of  treatment,  and  is  about  50 
per  cent.  Death  may  occur  in  less  than  one  hour  after  the  poison 
has  been  taken,  and  the  patient  seldom  lives  twenty-four  hours 
in  fatal  cases. 

Subacute  Poisoning.  If  smialler  quantities  of  the  poison  are 
introduced  into  the  body,  or  if  the  effect  of  a  large  dose  of 
arsenic  has  been  mitigated  by  treatment,  the  symptoms  charac- 
teristic oi  acute  arsenical  poisoning  come  on  more  slowly,  are 
milder  in  character,  and  continue  for  a  greater  length  of  time. 

The  gastro-intestinal  symptoms  are  prominent,  but  to  a  lesser 
degree  than  in  the  acute  foi'm,  of  poisoning.  If  death  occurs,  it 
usually  takesi  place  within  from  two  to  ten  days  after  the  poison 
is  ingested.  The  skin  becomes  dry  and  warm,  and  a  rash  may 
develop.  The  vomiting  may  be  intermittent  in  character.  At 
times  a  temporaiy  remission  of  the  symiptoms  occurs  about  the 
third  day,  and  this  is  followed,  as  in  a  case  of  phosphorus  poison- 
ing, by  jaundice  and  delirium. 

Disturbances  of  motion  are  usually  confined  tO'  the  extremi- 
ties. Muscular  atrophy  accompanies  the  paralysis  of  muscles. 
Disturbances  of  sensation  accompany  those  of  motion,  and  may 
predominate.  Pain  is  usually  present,  and  may  be  distressing  in 
character. 

A  neuritis  similar  in  character  to  that  caused  by  toxic  agents 
is  present  in  a  number  of  cases  of  chronic  arsenical  poisoning. 


420  THE   INTOXICATIONS. 

Chronic  arsenical  poisoning  may  result  from  the  long-con- 
tinued adniinistratioii  of  arsenical  preparations,  and  is  manifested 
by  disturbances  of  the  gastro-intestinal  tract  and  puffiness  under 
the  eyes.  ,  A  slight  fever,  mild  delirium,  dry  tongue,  rapid  pulse, 
and  often  a  cutaneous  eruption,  usually  predicate  death. 

Clironic  Poisoning.  Frequently  the  skin  bears  the  brunt  of 
chronic  arsenical  poisoning.  Arsenic  rashes  may  be  of  the  ery- 
thematous, papular,  vesicular,  pustular,  ulcerative  and  gangrenous 
types.  Pigmentation  of  the  skin  has  also*  followed  prolonged  use 
of  arsenic. 

Poisonous  doses  of  arsenic  have  a  very  destructive  efifect  on 
the  coloring  matter  of  the  blood.  In  some  casesi  transitory  or 
peniianent  paralysis  of  the  muscles,  or  sonue  weakening  thereof 
has  been  noted. 

In  addition  to  the  foregoing  symptoms,  prolonged  arsenical 
medication  may  result  in  other  lesions  of  the  skin  indicative  of 
cellular  proliferatio'n,  such  as  hyperkeratosis  of  the  hands  and 
feet. 

In  the  acute  form,  inflaniimation  of  the  gastro-intestinal  tract, 
nephritis  and  fatty  changes  in  the  muscles  and  the  viscera,  espe- 
cially the  liver,  constitute  the  prinoipal  lesiions ;  in  the  chronic 
form,  pigmentation  of  the  skin  and  lesianis  of  the'  nervous  sys- 
tem, notably  of  the  peripheral  nerves,  are  common. 

The  lesions  induced  by  the  arsenic  in  the  liver  and  kidneys 
are  easily  recognized  by  miicroscope;  only  exceptionally  have 
fatty  changes  advanced  sufficiently  to  be  recognized  by  the  eye. 

In  acute  arsenical  poisomng  hemorrhagic  areas  may  be  found 
in  the  alimentary  tract,  musdes,  pancreas,  lungs  and  serous  mem- 
branes. 

TREATMENT. 

In  acute  poisoning  the  stomach  should  be  emptied  by  the 
stomach-tube,  even  though  spontaneous  emesis  has  taken  place. 
Various  arsenical  preparations  in  powder  form  closely  adhere  to 
the  stomach  wall,  hence  the  necessity  of  thoroughly  washing  out 
the  stomach  with  an  abundance  of  water.  The  best  chemical  anti- 
dote is  the  freshly  prepared  ferric  hydroxid,  or  the  mixture 
of  ferric  hydrate  with  oxid  of  magnesia,  official  in  U.  S.  Phar- 
macopeia. 

It  is  a  very  good  practice  to  keep  the  iron  solution  and  the 
magnesia  mixture  in  separate  bottles  in  a  physician's  office,  so 


LEAD    POISONING.  421 

that  they  can  be  immediately  mixed  if  the  emergency  presents 
itself. 

The  iron  and  magnesia  preparation  can  be  given  freely,  a 
tablespoonful  (15  mils)  repeated  every  three  or  four  minutes 
for  one-half  hour.  These  substances  act  by  forming  insoluble 
arsenites;  as  in  other  irritant  poisons,  diluents,  demulcents,  and 
opiates  are  usually  indicated. 

LEAD    POISONING. 

Poisoning  by  lead,  or  plumbism,  is  by  far,  next  to  alcohol, 
the  most  important  intoxication  from  a  clinical  standpoint.  Acute 
lead  poisoning,  either  accidental  or  with  criminal  intent,  is  ex- 
tremely rare,  in  comparison  with  the  chronic  form  encountered 
in  workers  in  the  lead  industries. 

Considerable  improvement  in  the  working  conditions  of  em- 
ployees in  lead  occupations  has  resulted  in  fewer  cases  of  lead- 
intoxication  at  present  than  ten  years  ago.  There  is  need,  how- 
ever, for  further  lessening  the  dangers  of  these  occupations. 

The  symptoms  of  plimibism,  in  most  instances,  are  more  or 
less  common,  but  not  constantly  present.  Acute  lead  poisoning 
is  usually  accidental,  as  the  result  of  taking  the  acetate  of  lead, 
which  may  be  followed  by  serious  results,  which  eventuates  at 
times  in  death,  usually  within  two  or  three  days. 

The  symptoms  are  those  of  gastro-intestinal  origin,  and  con- 
sist of  vomiting,  retching*  and  colicky  pains,  with  obstinate  con- 
stipation. In  some  cases  the  vomiting  is  protracted,  and  is  of  a 
bloody  character.  The  pulse  becomes  rapid,  irregular;  the  breath- 
ing quickens,  becomes  shallow,  and  coma  may  precede  death. 

If  the  moderate  intoxication  of  lead  is  continued  over  a 
greater  or  lesser  length  of  time,  graver  s,ymptoms  and  conditions 
may  develop,  such  as  convulsions,  severe  headaches,  cardiovas- 
cular symptoms,  nephritis,  aiteriosclero'sis,  palsies,  and  even 
paresis.  Usually  the  symptoms  are  preceded  by  some  intestinal 
colic. 

The  subject  of  chronic  lead  poisoning  may  be  complaining  for 
a  number  of  years  of  poor  health  of  an  indefinite  nature.  Fre- 
quently death  resulting  from  nephritis  is  superinduced  by  lead. 

Abdominal  colic,  when  occurring  in  painters  and  others  en- 
gaged in  the  "lead  trades,"  should  always  suggest  a  chemical 


422  THE   INTOXICATIONS. 

examination  of  the  urine  for  lead,  unless  the  diagnosis  otherwise 
is  very  evident. 

A  grayish  or  black  deposit  of  lead  sulphid  near  or  at  the 
free  'margins  of  the  gums,  spoken  of  as  the  "blue  line,"  is 
characteristic  of  lead  poisoning.  Not  uncommonly  a  sweetish 
taste  in  the  mouth  is  experienced.  Wrist-drop  as  the  result 
of  affection  of  the  musculospiral  nerve  is  at  times  present  in 
this  form  of  intoxication. 

Disturbances  of  the  skin  are  impairment  in  sensation,  usually 
anesthetic  areas.  Altered  vision  is  occasionally  met  with  in  the 
form  of  amblyopia  and  amaurosis. 

Examination  of  the  blood  reveals,  in  a  large  percentage  of 
cases,  basic  granulation  of  the  erythrocytes.  While  this  condition 
is  seen  in  other  diseases,  it  is  important  to  remember  that  basic 
granulation  is  rather  constantly  found  in  chronic  lead  poisoning. 
The  number  of  erythrocytes  and  the  amount  of  hemoglobin  is 
reduced,  varying  with  the  severity  of  the  poisoning. 

TREATMENT. 

Acute '  poisoning,  unless  the  patient  has  vomited  and  thor- 
oughly emptied  the  stomach,  demands  that  a  stomach-pump 
should  be  used.  As  a  chemical  antidote,  a  solution  of  a  soluble 
sulphate  (sodium  or  magnesium)  should  be  given  in  full  do'Ses, 
so  that  the  purgative  efifect  may  be  obtained.  This  solution  can 
be  given  directly  into-  the  stomach  through  the  stomach-tube  after 
the  stomach  has  been  thoroughly  washed.  The  resulting  gastro- 
enteritis should  be  treated  by  the  application  of  heat  tO'  the 
abdomen  locally;  only  demulcent  drinks  and  liquids  by  mouth; 
and,  if  pain  is  intense,  simall  doses  of  opium  preparations. 

Chronic  Poisonings.  Lesseniing  the  dangers  in'  the  "lead  in- 
dustries" will  do  much  toward  decreasing  chronic  plumbism. 
Absolute  cleanliness,  especially  of  the  hands  and  nails,  is  of 
utmost  importance.  Fans,  face-masksi,  and  suitable  means  of 
ventilation  should  be  provided  wherever  dust  is  generated.  No 
food  should  be  eaten  in  any  part  of  the  works. 

Treatment  should  be  directed  toward  eliminating  the  poisons 
and  in  relieving  the  immediate  symptoms.  Constipation  should 
be  relieved  by  saline  cathartics,  preferably  Glauber  or  Epsom 
salts. 


PHOSPHORUS    POISONING.  423 

Hot  packs  or  other  means  of  inducing  perspiration  are.  of 
great  aid  in  the  elimination  of  lead,  and  at  the  same  time  relieve 
the  kidneys  of  part  of  their  work. 

Potassium  iodid,  in  doses  of  5  ta  15  grains  (0.3  to  1  Gm.) 
three  times  a  day,  aids  in  the  elimination  of  the  lead. 

Sulphur  baths  have  been  recommended  as  giving  good  results. 
They  are  prepared  by  mixing  in  a  wooden  tub  3  or  4  ounces 
(90  or  120  Gms.)  of  potassium  sulphuret  with  about  20  gallons 
(80  1.)  of  water. 

Colic  will  require  hot  applications  tO'  the  abdomen,  opiates  and 
atropin  hypodermically. 

For  the  paralysis,  strychnin,  massage,  and  electricity  are 
valuable  means  of  treatment. 

PHOSPHORUS    POISONING. 

Acute  poisoning  by  phosphorus  is  not  common,  and  usu- 
ally results  from  the  swallowing  or  administration  of  phos- 
phorus match-heads  with  suicidal  intent. 

At  the  present  time  chronic  poisoning  by  phosphorus  is 
rare,  and  occurs  in  localities  containing  phosphorus  indus- 
tries. 

Important  changes  take  place  in  the  blood  and  liver.  The 
coagulability  of  the  blood  is  reduced,  and  hemorrhages  occur 
into  the  skin  and  mucous  membranes.  There  is  jaundice,  and 
fatty  degeneration  of  the  viscera  and  muscles,  especially  the 
liver  which  undergoes  enlargement,  and  changes  to  a  bright 
safifron  color — a  type  of  fatty  icteric  liver. 

The  liver  and  blood  contain  intermediate  products  of  pro- 
tein metabolism  such  as  leucin,  tyrosin,  and  sarcolactic  acid. 
Sugar  may  be  found  in  the  urine.  As  a  result,  the  ammonia  is 
greatly  increased,  urea  decreased,  and  the  condition  of  acidosis 
is  present. 

In  chronic  phosphorus  poisoning  the  chief  pathologic  change 
consists  of  necrosis  of  the  inferior  maxilla  and  surrounding  tis- 
sues, with  suppuration  and  formation  of  sequestra.  These 
lesions,  fortunately  not  of  common  occurrence  at  the  present  day, 
become  very  extensive  unless  treated  promptly. 

Acute   phosphorus   poisoning  bears   a   close   resemblance   to 


424  THE   INTOXICATIONS. 

icterus  gravis  and  to  acute  yellow  atrophy,  of  the  liver,  from 
which  it  must  be  differentiated. 

Soon  after  the  poison  has  been  ingested,  vomiting  and 
diarrhea  are  noted,  and  these  symptoms  tend  presently  to  sub- 
side, only  to  reappear  in  two  or  three  days,  accompanied  by 
jaundice,  pain  in  the  abdomen,  and  pains  and  tenderness  in  the 
muscles  of  the  body.  Fever  in  moderate  amount  is  often 
present. 

At  this  time  blood  in  the  vomitus  and  stools,  petechia,  and 
submucous  hemorrhages  appear.  The  liver  enlarges  in  from 
two  to  four  days  after  the  onset  of  symptoms,  and  is  tender. 
Later  a  decrease  in  size  will  occur  if  the  patient  recovers. 

Profound  asthenia,  with  maniacal  excitement.,  is  followed 
in  fatal  cases  by  stupor  and  co'ma,  ending  by  death,  which  usu- 
ally takes  place  within  a  week  after  the  onset  of  symptoms. 

If  recovery  takes  place,  the  liver  gradually  returns  to  nor- 
mal size,  and  the  general  condition  of  the  subject  improves, 
but  the  heart  commonly  shows  some  degree  of  myocardial 
weakness,  caused  by  fatty  degeneration. 

In  the  chronic  form  of  poisoning,  necrosis  of  the  jaw  com- 
monly begins  about  a  single  tooth,  with  inflammation  and 
abscess  formation. 

Usually  not  only  the  teeth  but  also  the  surrounding  tissues 
are  affected.  The  pus  is  generally  abundant  and  very  foul.  As 
the  result  of  necrosis,  one  or  several  sequestra  may  form. 

Rapid  anemia  and  general  sepsis  may  occur  in  neglected 
cases  of  either  variety  of  poisoning. 

TREATMENT. 

If  red  phosphorus  were  used  in  the  manufacture  of  all 
matches,  instead  of  white  phosphorus,  poisoning  by  phos- 
phorus would  be  practically  eliminated. 

The  treatment  of  the  necrosis  consists  of  removing  the 
subject  from  the  danger  of  exposure  to  phosphorus,  and  im- 
mediate surgical  and  dental  care. 

Acute  poisoning  should  be  treated  by  an  emetic,  preferably 
copper  sulphate,  both  for  its  emetic  effect  and  because  it  pre- 
vents absorption.  By  means  of  a  stomach-tube  gastric  lavage 
should  be  performed,  using  either  a  2  per  cent,  solution  of  per- 
manganate of  potash  or  a  solution  of  peroxid  of  hydrogen  1 


COPPER,   ZINC,   AND   TIN    POISONING.  425 

to  3  per  cent.  Old  spirits  of  turpentine  has  been  given  in  doses 
of  0.5  mil  (7  m.)  in  milk  for  a  period  of  a  week.  Permanganate 
of  potash,  hydrogen  peroxid  solution,  and  old  spirits  of  tur- 
pentine are  used  because  their  oxidizing  properties  render 
the  phosphorus  practically  non-poisonous.  Alkalies  should 
be  given  freely,  and  are  of  value  in  the  treatment  of  acidosis. 
The  alkalies  may  be  given  by  mouth,  bowel  or  intravenous 
injection,  if  urgently  needed. 

COPPER,    ZINC,    AND    TIN    POISONING. 

Copper.  Soluble  salts  of  copper,  if  taken  in  sufficiently 
large  quantities,  can  produce  acute  poisoning.  Chronic  poison- 
ing, by  soluble  salts  of  copper  is  very  uncommon,  as  evidenced 
by  the  infrequency  of  such  case  in  workers  in  and  about  this 
metal. 

The  symptoms  of  acute  poisoning  are  necessarily  variable, 
inasmuch  as  the  soluble  salts  of  copper  in  poisonous  doses  act 
as  emetics.  Severe  gastro-enteritis,  to  which  may  be  added  in 
twenty-four  hours  a  hemolytic  jaundice,  with  symptoms  of  an 
acute  parenchymatous  nephritis,  make  up  the  picture  of  acute 
poisoning.  The  urine,  in  addition  to  the  findings  of  the  acute 
nephritis,  gives  a  positive  test  for  the  presence  of  copper. 

Even  though  the  copper  has  been  vomited,  owing  to  its 
emetic  action,  the  stomach  should  be  thoroughly  washed  out 
with  an  abundance  of  water.  Demulcent  drinks,  white  of  eggs, 
milk,  or  some  albuminous  substance  is  used  to  limit  or  prevent 
the  corrosive  action  of  the  copper.  Frequent  irrigation  of  the 
bowels  is  of  utmost  importance. 

Elimination  should  be  encouraged  by  taking  an  abundance 
of  water,  and  by  sweating  induced  by  hot  packs  or  cabinet 
baths. 

The  chemical  antidote  is  ferrocyanide  of  potash,  which 
forms  an  insoluble  salt  with  the  copper.  The  irrigation  of 
the  stomach  and  intestines  is  necessary,  and  the  administration  of 
a  chemical  antidote  is  merely  an  aid  in  the  prevention  of  absorp- 
tion of  copper. 

Zinc,  like  copper,  if  given  in  sufficiently  large  doses,  exerts 
an  emetic  action,  and  therefore  its  toxic  eflfect  in  acute  poison- 


426  THE   INTOXICATIONS. 

ing  depends  upon  the  size  of  dose  and  the  emetic  effect  thereof. 
Recoveries  from  large  poisonous  doses  may  occur. 

Zinc  chlorid,  sulphate,  and  sulphid  are  the  salts  com- 
.monly  used  in  medicine  and  in  the  arts.  The  question  of  acute 
poisoning  from  the  use  of  zinc  solder  used  in  sealing  various 
canned  goods,  is  so  questionable  that  it  does  not  warrant  seri- 
ous consideration.  It  has  been  found  that  individuals  mani- 
festing poisonous  symptoms  after  partaking  of  the  contents  of 
a  can  in  which  zinc  solder  has  been  used  are  suffering  from 
poisonous  effects  of  food^  rather  than  the  effects  of  the  zinc. 
The  acute  poisoning  by  zinc  salts  is  characterized  by  active 
gastro-intestinal  symptoms,  and  ma}^  be  followed  later  by  con- 
vulsions and  epileptiform  fits.  Zinc  chlorid  locally  produces 
a  corrosive  action  upon  the  skin  and  mucous  membranes. 

Chronic  poisoning  by  zinc  is  very  unlikely,  and  the  ill 
effects  produced  in  the  zinc  industries  are  from  the  inhalation 
of  dust  of  other  metals,  such  as  lead  and  arsenic,  from  a  gas 
like  carbon  monoxide,  or  from  the  fumes  of  sulphuric  and  sul- 
phurous acids. 

Washing  out  the  stomach  and  rest  for  the  gastro-intestinal 
tract  are  the  first  indications.  Thirst  may  be  relieved  by  giv- 
ing fluids  by  the  rectum,  or  subcutaneously,  if  no  fluid  can  be 
taken  by  mouth.    Mucilaginous  drinks  should  be  given. 

Tin.  Poisoning  by  tin  is  in  all  probability  very  uncommon, 
inasmuch  as  the  evidence  shows  that  when  poisoning  was 
thought  to  have  resulted, from  the  container  as  in  canned  goods 
in  tin  containers,  the  intoxication  resulted  from  decomposed 
food  which  had  been  canned. 

SILVER    POISONING    OR    ARGYRIA. 

Poisoning  by  silver  is  but  exceptionally  always  chronic  in 
type.  When  taken  internally,  especially  having  been  pre- 
scribed over  several  months  or  more  in  therapeutic  doses,  gen- 
eral argyria  may  result.  Local  argyria  in  those  who  handle 
silver  in  their  occupations  when  seen  is  chiefly  in  the  skin  of 
the  hands.  The  prolonged  local  use  of  silver  preparations  may 
result  in  local  argyria.  As  the  result  of  the  dangers,  argyria 
is  fortunately  not  very  common. 


ILLUMINATING   GAS    POISONING.  427 

The  pathology  of  argyria,  briefly  stated,  is  a  deposit  of 
silver  in  the  skin  or  mucous  membrane  alone  if  in  the  local 
form.  In  g-eneralized  argyria,  in  addition  to  the  skin  and 
mucous  membrane,  scarcely  a  tissue  of  the  body  but  that  con- 
tains deposits  of  silver.  Chronic  interstitial  changes,  as  the 
result  of  irritation  produced  by  the  deposit  of  silver,  occur  in 
the  lungs,  liver,  kidneys,  and  spleen.  The  brain,  its  covering, 
and  the  blood-vessels  are  at  times  afifected  by  the  sclerosis 
produced  by  the  silver  deposits. 

The  principal  manifestation  of  the  disease  is  the  pigmenta- 
tion without  subjective  symptoms.  A  line  is  noted  on  the 
gums  similar  to  the  line  in  lead  poisoning,  but  of  a  more 
decidedly  violet  color.  The  color  may  appear  even  following 
the  discontinuance  of  the  use  of  silver  salts. 

TREATMENT. 

No  known  treatment  will  change  the  pigmentation  for  the 
better.     Once  present  always  present. 

Silver  nitrate  should  not  be  given  in  more  than  y\-gra.\n 
(0.015  Gm.)  doses,  and  not  longer  than  for  one-month  periods, 
with  from  two-  to  four-  week  intervals. 

Local  applications  should  be  used,  under  the  direction  of 
the  physician,  who  will  see  that  the  patient  is  warned  against 
the  continued  use  of  the  metal,  cautioning  him  about  the  dan- 
ger of  chronic  poisoning. 

ILLUMINATING    GAS    POISONING. 

For  practical  consideration,  the  poisonous  effect  produced 
by  illuminating  gas  may  be  considered  identical  to  that  of  car- 
bon monoxid  poisoning.  While  it  has  been  shown,  chemically 
and  experimentally,  that  the  effects  produced  by  illuminating  gas 
are  not  identical  to  those  of  pure  carbon  monoxid,  nevertheless 
no  other  constituent  of  illuminating  gas  will  produce  so  close  a 
typical  picture  as  that  of  carbon  monoxid. 

Gas  poisoning  is  a  method  frequently  used  to  commit 
suicide,  probably  so  because  of  its  easy  accessibility  in  towns 
and  cities.  In  addition  to  death  produced  b}^  intentional  in- 
halation, many  deaths  have  resulted  through  improper  closure 


428  THE    INTOXICATIONS. 

of  gas  jets  and  cocks,  and  through  leaks  in  gas  conduits.  Gas 
poisoning  ma}-  be  acute  and  chronic. 

Illuminating  gas  manufactured  from  coal  contains  5  to  10 
per  cent,  of  carbon  monoxid,  while  that  made  from  wood  may 
contain  as  much  as  60  per  cent.  Water-gas,  so  largely  made 
for  illuminating  and  cooking  purposes,  contains  approximately 
30  per  cent.  Cases  of  chronic  poisoning,  strange  as  it  may 
seem,  often  escape  recognition  because  of  the  difference  in 
cause  and  effect,  as  compared  with  acute  cases.  Slow  leaks  in 
gas  fixtures  may  produce  symptoms  which  often  are  not 
recognized  as  being  of  gas  origin  until  it  has  been  noticed  that 
with  the  discovery  and  repair  of  gas-leaks  the  health  of  an 
individual  or  group  of  individuals  has  returned  to  normal. 
The  leak  need  not  be  in  the  building,  but  may  travel  through 
the  ground  for  some  distance  before  entering  a  house.  The 
characteristic  odor  of  illuminating  gas  in  such  cases  is  usu- 
ally lost. 

Poisoning  by  combustion  or  incomplete  combustion  products 
such,  as  are  produced  in  a  heating  apparatus  with  poor  draught 
in  charcoal,  iron,  and  other  furnaces,  and  in  the  coal-tar  indus- 
tries, is  due  chiefly  to  the  effects  of  carbon  monoxid.  The 
poisonous,  effects  produced  by  the  use  of  the  gas-  and  oil-  stoves 
in  small  and  poorly  ventilated  rooms  are  striking,  and  should  be 
guarded  against. 

In  acute  cases  of  poisoning,  the  striking  changes  produced  are 
widespread  in  the  body.  The  deadly  effects  of  carbon  monoxid 
are  due  to  the  readiness  with  which  the  gas  combines  with  the 
hemoglobin,  and  to  the  stability  of  the  compound  thus  fonned. 
The  skin  is  bluish  or  bluish-red  as  the  result  of  extravasations 
beneath  the  skin.  The  body  presents  a  mottled  appearance.  The 
muscles  show  degenerative  changes,  and  scarcely  an  organ  or 
tissue  escapes  the  hyperemia  and  scattered  small  hemorrhages. 
The  respiratory  tract  may  present  a  bronchitis,  or  bronchopneu- 
monia; rarely  a  lobar  pneumonia  develops.  Quite  commonly  the 
kidneys  show  acute  parenchymatous  changes.  Cerebral  symptoms 
may  be  present,  owing  to  the  multiple  scattered  hemorrhages 
throughout  the  brain  tissue. 

In  chronic  poisoning  the  fatty  changes  in  the  cardiovascular 
system  are  noted.    Marked  anemia  is  due,  in  part,  to  the  destruc- 


ILLUMINATING   GAS    POISONING.  429 

tion  of  the  erythrocytes,  and  in  part  to  the  failure  of  kidney 
action. 

The  combination  formed  by  the  gas  and  hemoglobin  is  a 
staple  one;  that  is,  the  hemoglobin  no  longer  carries  oxygen,  and 
as  a  result  the  tissues  suffer  asphyxiation.  With  proper  treat- 
ment individuals  severely  poisoned,  and  apparently  fatally  ill, 
may  recover. 

The  symptoms  of  acute  gas  poisoning  have  been  variously 
described  by  those  who^  have  recovered.  The  clinical  picture 
ordinarily  is  that  of  severe  headache  witli  early  a  throbbing  of 
the  blood-vessels,  accompanied  by  a  burning  sensation  in  the  face, 
nausea  and  vomiting,  and  attacks  of  vertigo,  with  rapid  oncoming 
muscular  weakness.  The  subject  becomes  drowsy,  and  slowly 
passes  into  an  unconscious  state.  Muscular  twitchings  are  often 
alone  present  or  associated  with  convulsions. 

It  must  not  be  forgotten  thait  frequently  a  poison  is  taken  by 
mouth  with  suicidal  intent,  and,  in  order  to  accomplish  the  in- 
dividual's object,  he  further  inhales  gas,  so  that  the  clinical  pic- 
ture that  is  presented  to  the  physician  is  a  double  one.  This  fact 
must  be  borne  in  mind  in  the  treatment  of  what  appears  to  be  a 
gas  poisoning  case  with  unusual  symptoms. 

Drawn  blood  presents  the  cherry-red  color,  and  gives  the 
chemical  and  spectroscopic  tests  for  carbon  monoxid.  Con- 
valescence may  be  very  slow,  and  a  confused  mental  state  may 
at  times  entirely  escape  recognition. 

The  sequelae  of  the  acute  poisoning  deserve  special  mention. 
The  respiratory  tract  may  be  affected  to  the  extent  of  pneumonia. 
Nephritis  may  be  acute,  only  to  end  in  a  chronic  form. 

The  heart  and  blood-vessels  seldom  escape  without  more  or 
less  permanent  isequelse.  Irregular  heart  or  palpitation  often 
occurs  for  an  indefinite  period  afterward. 

Probably  the  nervous  system  is  implicated  more  markedly 
than  any  other  system.  The  various  paralyses,  choreiform  move- 
ments, anesthesias,  neuralgias,  tremors,  alteration  of  speech,  have 
been  observed.  Changes  in  the  special  senses,  such  as  deafness 
of  different  grades,  associated  with  roaring  noises  in  the  ears, 
occur;  various  ocular  disorders  are  not  vei"}'  common. 

The  mental  changes  vary  in  type,  and  include  simple  confu- 
sion, delirium,  mild  or  noisy,  and  hallucinations;  simple  dementia 
may  persist. 


430  THE    INTOXICATIONS. 

Chronic  poisoning  may  be  difficult  to  distinguish,  or  It  may 
at  times  entirely  escape  recognition.  A  history  of  gas  leaks,  or 
workers  about  the  gas  industries  and  associated  therewith,  with 
headache,  nausea,  vomiting,  poor  health,  mental  disturbances,  lack 
of  concentration,  sluggish  intellectual  action,  make  up  a  picture 
of  chronic  gas  poisoning. 

TREATMENT. 

The  treatment  of  acute  poisoning  consists  of  prompt  removal 
of  the  subject  from  the  gas-laden  atmosphere.  Oxygen  should 
be  freely  supplied.  To  what  extent  oxygen  in  excess  of  the 
amount  present  in  the  fresh  air  is  absorbed  is  a  much  disputed 
question. 

Artificial  respiration  and  various  mechanical  devices,  such  as 
pulmotor,  lungmotor,  are  used  in  resuscitation. 

\^enesection,  promptly  followed  by  saline  infusion,  or  direct 
transfusion  of  blood,  is  a  life-saving  measure. 

The  circulation  may  require  stimulation  by  digitalis,  strych- 
nin, cafTein  or  atropin  in  dosage  necessary  to  produce  prompt 
results.  External  heat  is  indicated  if  the  temperature  has  dropped 
below  normal. 

The  patient  should  be  carefully  watched,  since  he  may  at  any 
time  (if  the  gas  has  been  taken  with  suicidal  intent)  further  seek 
means  to  accomplish  his  purpose.  The  fact  also  must  not  be  lost 
sight  of  that  the  patient  may  be  sufifering  from  the  efifect  of 
another  poison  in  addition  to  gas,  e.g.,  bichlorid  of  mercury  or 
acute  alcoholism.  Tonics  are  a  necessary  detail  in  the  after- 
treatment  of  this  sort  of  cases. 

COCAINISM. 

While  therapists  are  divided  with  regard  to  the  desir- 
ability of  withdrawing  morphin  gradually  or  suddenly,  they 
are  in  more  general  accord  in  advising  the  immediate  with- 
drawal of  cocain  in  cases  of  chronic  poisoning  by  this  drug. 
The  symptoms  of  immediate  withdrawal,  such  as  insomnia, 
palpitation,  dyspnea  and  collapse,  are  often  quite  as  distress- 
ing as  in  morphinism,  but  are  more  readily  controlled.  The 
success  of  treatment  in  any  given  case  is  dependent  upon  the 
presence  or  absence  of  a  previous,  neuropathy,  the   circum- 


COCAIXISM.  431 

stances  under  which  the  habit  was  contracted,  the  length  of 
time  it  has  existed,  and  the  association  with  other  drug  addic- 
tions, such  as  morphin  and  alcohol.  In  some  instances  it 
is  the  indirect  outcome  of  nasal  surgery  (Dercum).  IMany 
nasal  applications  contain  cocain,  and  their  use  may  cause 
the  cocain  habit,  but  in  most  cases  it  is  acquired  by  morphin 
habitues  who  go  to  cocain  in  the  expectation  of  finding  help 
in  their  struggle  against  the  tyranny  of  the  former  drug.  In 
this  hope,  however,  they  are  always  disappointed  when  the 
drugs  are  in  their  own  hands.  The  victim  soon  finds  that  one 
of  these  agents  antag'onizes  the  other  to  a  great  extent,  while, 
at  the  same  time,  it  sets  up  peculiar  troubles  of  its  own;  and 
that  there  is  a  constant  need  of  more  morphin  to  counteract 
the  cocain  symptoms,  and  of  more  cocain  to  antagonize  the 
symptoms  due  to  the  increased  amount  of  morphin.  The 
result  is  that  one  who  is  using  only  a  moderate  daily  amount 
of  morphin,  if  cocain  be  added,  will  soon  be  taking  a  great 
amount  of  morphin,  as  well  as  of  cocain,  and  "the  last  state 
of  that  man  is  worse  than  the  first."  Drug  fiends  who  use 
both  drugs  frequently  state  that  cocain  is  not  a  habit  in  the 
sense  applied  to  morphin.  The  latter  when  once  started 
requires  daily  use ;  cocain,  however,  is  used  more  for  periodic 
debauches,  known  by  the  Tenderloin  dweller  as  "coke  sprees" 
and  "coke  parties,"  in  the  intervals  of  which  there  may  be 
little  or  no  craving  for  the  drug.  Cocain  therefore  can  be 
removed  promptly  by  treatment,  and  with  less  suffering  than 
in  the  case  of  morphin. 

TREATMENT. 

In  treating  cocainism  we  must  realize  a  total  irresponsi- 
bility on  the  part  of  the  patient,  and  that  no  effort,  short  of 
placing  him  in  an  institution,  isolated  from  everyone  except 
his  physician  and  two  trusted  attendants  who  can  carry  out 
every  detail  of  treatment,  will  avail.  The  most  effective  treat- 
ment is  known  as  the  Tozvns-Lambert  treatment,  and  is  the 
same  as  that  applied  for  alcoliolism,  except  that  no  cocain  is 
given  at  any  time,  and  that  strychnin  or  some  such  stimulant 
must  be  given  from  the  beginning.  (See  p.  439.)  The  mix- 
ture of  belladonna — xanthoxylum  and  hyoscyamus  (tincture 
of  belladonna    [15   per  cent.],  2  parts;   fluidextracts   of  xan- 


432  THE   INTOXICATIONS. 

thoxylum  and  hyoscyamus,  each  1  part) — with  5  grains 
(0.33  Gm.)  of  blue  mass  and  5  compound  cathartic  pills,  are 
g-iven  simultaneously  at  the  first  dose.  The  belladonna  mix- 
ture is  continued  every  hour  of  the  day  and  every  hour  of  the 
night,  the  same  as  with  the  morphin  patients,  and  twelve . 
hours  before  the  initial  dose  patients  are  again  given  from  3  to 
5  compound  cathartic  pills,  and  at  the  twenty-fourth  hour  after 
the  initial  dose  they  are  again  given  the  cathartics,  followed 
by  salines  if  necessary,  and  again  at  the  thirty-sixth  hour. 
After  these  last  cathartics,  the  bilious  stools  will  appear,  and 
by  the  forty-fourth  or  forty-fifth  hour  the  castor  oil  is  given. 
Sometimes  it  is  necessary  to  carry  on  the  treatment  over 
another  period,  and  the  compound  cathartic  pills  and  blue 
mass  are  again  given  at  the  forty-eighth  hour.  It  may  even  be 
necessary  to  carry  on  the  treatment  one  or  two  periods  longer. 
If  these  patients  are  excessively  nervous  it  is  necessary  also 
to  see  that  they  sleep,  and  the  mixture  of  chloral  hydrate,  20 
grains  (1.3  Gm.)  ;  morphin,  }i  grain  (0.0082  Gm.)  ;  tincture 
of  hyoscyamus,  >4  dram  (7.5  mils)  ;  tincture  of  ginger,  10 
minims  (0.67  mil)  ;  tincture  of  capsicum,  5  minims  (0.33  mil)  ; 
and  water,  j^  ounce  (15  mils),  is  the  best  hypnotic  for  them. 
These  patients  should  also  have  cardiac  stimulants  such  as 
strychnin  and  digitalis  after  the  first  twenty-four  hours,  or 
sooner  if  they  are  weak. 

The  result  of  this  treatment  is  a  complete  obliteration  of 
the  terrible  craving  that  these  patients  suffer,  and  it  is 
infinitely  superior  to  gradual  withdrawal  of  the  drug.  As  a 
rule  the  active  treatment  so  instituted  does  not  cover  a  period 
of  more  than  two  or  three  weeks  at  the  most.  Adjuvant 
treatment  resolves  itself  into  improving  the  patient's  mental 
attitude  and  general  physical  condition.  Hydrotherapy, 
massage,  gentle  exercise,  nutritious  food,  an  abundance  of 
rest,  and  all  that  makes  for  a  healthful  and  invigorating 
environment  should  be  placed  at  the  disposal  of  the  patient. 
For  sleeplessness  the  bromids  are  very  efficacious,  and  in 
some  instances  moderate  doses  of  trional  or  sulphonal. 

The  difficulty  in  all  these  cases  lies  in  the  fact  that, 
although  they  have  been  freed  from  the  desire,  the  contin- 
uance of  the  cure  is  largely  in  their  own  hands,  and  a  return 
to  the  former  environment  and  habits  of  life  leads  to  relapses. 


OPIUM    POISOXIXG.  433 

The  problem  then  becomes  one  of  mental  regeneration,  which 
is,  perhaps,  the  most  difficult  phase  of  the  treatment. 

When,  as  a  result  of  profound  intoxication,  the  patient  has 
passed  beyond  the  legal  boundary  of  sanity  he  can  be  com- 
mitted and  restrained  in  an  institution;  but,  as  Dercum  states, 
it  is  unfortunate,  to  say  the  least,  that  we  must  frequently 
wait  until  gross  insanity  supervenes  before  efifective  treatment 
can  be  instituted. 

OPIUM    POISONING. 

The  recognition  of  acute  opium  poisoning  is  based  partly 
upon  the  history  and  partly  upon  symptoms,  such  as  slow, 
stertorous  breathing,  livid  cyanosis,  contracted  pupils,  warm 
and  dry  skin,  cold  sweats,  slow,  full  pulse,  and  drowsiness,  if 
not  deep  sleep. 

TREATMENT. 

Gastric  lavage  should  be  promptly  resorted  to.  unless 
emesis  has  been  very  thorough.  This  procedure  is  indicated 
regardless  of  the  time  that  has  elapsed  since  the  opium  or  any 
of  its  preparations  have  been  introduced  into  the  body.  It  is 
necessai-y  that  gastric  lavage  be  practised  early,  because  it  has 
been  shown  experimentally  on  animals  that  morphin  given 
subcutaneously  can  be  recovered  from  the  stomach ;  if  allowed 
to  remain  in  the  stomach  it  may  be  reabsorbed  by  the  gastric 
mucosa.  A  1 :  500  solution  of  permanganate  of  potash  has 
proved  most  efficacious  for  use  in  gastric  lavage.  Several 
ounces  should  be  permitted  to  remain  in  the  stomach  after 
the  lavage  has  been  completed,  in  order  thus  to  neutralize  the 
opium  eliminated  into  the  stomach. 

The  patient  should  receive  at  intervals  4  to  6  ounces  (120 
to  180  mils)  of  warm  cofifee  by  the  rectum.  Artificial  respira- 
tion should  be  kept  up  if  the  skin  indicates  too  great  de- 
pression of  the  respiratory  center. 

Strychnin  hypodermically,  %o  to  %o  grain  (0.002  to  0.006 
Gm.)  is  most  valuable  in  combating  respiratory  failure, 
and  it  exerts  a  stimulating  effect  upon  the  nervous  system. 
Atropin  sulphate  in  doses'  of  i/ioo  to  l^o  grain  (0.0006  to 
0.0013  Gm.)  is  used  for  a  similar  purpose,  but  not  as  suc- 
cessfully. 

28 


434  THE   INTOXICATIONS, 

If  the  patient  can  swallow,  the  administration  of  stimulants 
b}^  the  mouth,  such  as  aromatic  spirits  of  ammonia  or  whisky, 
may  be  resorted  to  advantageously. 

Since  every  effort  should  be  directed  to  keep  up  the  activity 
of  a  paralyzed  respiratory  center,  patients  are  frequently 
lashed  with  wet  sheets  or  towels,  or  walked  about,  even  if 
in  an  exhausted  condition.  This  procedure  should  be  used 
only  as  a  last  resort,  and  in  the  absence  of  a  better  method, 
which  consists  in  the  application  of  the  full  force  current  of 
an  ordinary  medical  battery.  The  two  small  poles  wet  with 
salt  solution,  or,  better  still,  a  wire  electric  brush,  should  be 
swept  over  the  body,  while  the  negative  pole  is  held  in  the 
hand  of  the  patient  or  pressed  against  the  skin  (Hare). 

In  the  advanced  stage  external  heat  is  necessary  to  main- 
tain body  temperature. 

Treatment  of  Morphinism  or  the  Morphin  Habit.  The 
opium  habit  consists  of  the  introduction  into  the  body  of  vari- 
ous alkaloids  or  preparations  of  opium,  or  containing  opium. 
Morphin  seems  to  be  the  most  frequently  used  alkaloid  of 
opium;  codein,  heroin,  somewhat  less  so.  Regardless  of  the 
form  in  which  the  patient  takes  the  drug,  the  treatment  is 
practically  the  same. 

Many  of  the  reputed  and  extensively  advertised  remedies 
for  the  cure  of  the  opium  habit  have  been  shown  to  consist 
largely,  if  not  entirely,  of  some  form  of  opium.  As  a  result 
of  an  active  campaign  by  the  Federal  agents  and  the  enact- 
ment of  the  Federal  Anti-Narcotic  Law,  this  practice  has  been 
almost  annihilated. 

The  addicts  of  this  habit  long  to  free  themselves  from  the 
slavery  of  the  habit,  but  it  requires  great  will-power  to  give 
the  co-operation  which  is  so  essential  to  successful  treatment. 

Special  institutions  and  wards  are  best  adapted  for  carry- 
ing out  successfully  the  treatment  for  morphinism.  The 
principles  governing  the  method  of  treatment  are :  rapid 
elimination  of  the  drug  from  the  body,  and  the  control  of  the 
symptoms  resulting  from  withholding  the  drug,  with  a  drug 
of  the  belladonna  group,  and  lessening  the  amount  of  opium 
taken  as  rapidly  as  conditions  will  permit. 

Numerous  treatments,  differing  however  in  details,  have 
been  successfully  used. 


OPIUM    POISONING.  1435 

It  is  imperative  to  isolate  the  patient  from  his  friends,  and 
to  be  sure  that  the  attendants  are  trustworthy,  thereby  being 
assured  that  the  patient  will  receive  no  drug  except  upon  the 
physician's  orders. 

The  writer  has  known  a  patient,  using  considerable  quanti- 
ties of  morphin,  who  put  himself  under  treatment  for  mor- 
phinism, and  in  spite  of  rapid  withdrawal  of  the  drug  no 
symptoms  were  complained  of  as  the  result  of  withholding 
the  morphin.  An  investigation  was.  instituted  to  ascertain 
the  source  of  the  supply  of  the  drug  which  the  attending 
physician  felt  confident  the  patient  was  receiving.  Finally  it 
developed  that,  at  the  request  of  the  patient,  who  was  per- 
mitted to  receive  eggs  from  a  certain  shop  in  which  a  friend 
of  his  was  employed,  this  friend  injected  morphin  by  means 
of  a  hypodermic  syringe  into  each  egg,  thereby  keeping  the 
patient  very  comfortable  on  his  morphin  supply.  When 
eggs  were  no  longer  obtained  from  this  source  an  immediate 
change  was  noted. 

Belladonna  and  hyoscyamus  are  used  to  the  point  of  dry 
throat  and  the  stage  of  dilated  pupils  with  maintained  con- 
sciousness and  freedom  of  action.  The  prescription  used  is 
composed  as  follows : 

Tincture  of  belladonna  15%    2  parts. 

Fluidextract   hyoscyamus    1  part. 

Fluidextract  xanthoxylum    1  part. 

This  mixture  must  be  used  until  the  full  effect  of  the  bella- 
donna is  obtained,  and  of  course  the  maximum  amount  must 
vary  with  the  patient. 

Towns'  treatment  is  well  known  as  a  successful  method  of 
curing  chronic  opium  poisoning. 

The  details  of  treatment  as  stated  by  Lambert  are  as 
follows :  The  patient  is  given  5  compound  cathartic  pills 
U.  S.  P.  and  5  grains  (0.32  Gm.)  of  blue  mass.  If  at  the  end 
of  six  hours  no  action  of  the  bowels  has  resulted,  a  saline  is 
administered.  After  thorough  action  of  the  bowels  has  been 
obtained,  in  three  divided  doses,  at  one-half  hour  intervals, 
two-thirds  or  three-fourths  of  the  total  dailv  dose  to  which  the 
patient  has  been  accustomed  is  given. 

The  larger  amount  of  the  drug  prevents  the  disturbance  to 
the  patient  that  would  otherwise  be  experienced  if  the  dose 


436  THE   INTOXICATIONS. 

were  very  much  lessened.  After  the  second  dose  of  morphin 
has  been  given,  observe  the  effect  upon  the  patient,  since  this 
quantity  should  be  sufficient  to  keep  the  patient  comfortable; 
in  fact  sorne  patients  cannot  take  with  ease  the  third  dose  of 
morphin.  The  belladonna  mixture  in  6-drop  doses  (0.4  mil) 
is  given  every  hour  for  six  doses.  At  the  end  of  six  hours  the 
dose  is  increased  to  8  drops  (0.5  mil),  and  dosage  is  increased 
every  six  hours  until  16  drops  (1.0  mil)  are  taken,  when  it  is 
continued,  as  heretofore,  hourly  as  the  fixed  dosage. 

If  the  patient  shows  excessive  belladonna  symptoms,  it  is 
diminished  or  discontinued.  Widely  dilated  pupils,  exces- 
sively dry  throat,  erythema  of  the  skin,  or  a  peculiar  incisive 
and  insistent  voice,  and  an  insistence  on  one  or  two  ideas, 
indicate  that  the  belladonna  medication  must  be  reduced  or 
discontinued.  After  the  symptoms  have  subsided,  the  bella- 
donna mixture  is  beg'un  at  a  reduced  dosage,  and  gradually 
increased  to  the  point  of  tolerance. 

Ten  hours  after  the  initial  dose  of  morphin  is  given,  3  to 
5  compound  cathartic  pills  and  5  grains  (0.32  Gm.)  of  blue 
mass  are  repeated,  followed  by  a  saline  in  six  hours,  unless 
the  bowels  have  been  thoroughly  evacuated.  After  the  bowels 
have  acted  satisfactorily  the  second  dose  of  morphin  is  given, 
which  is  usually  about  the  eighteenth  hour.  This  should  be 
one-half  the  original  dose,  i.e.,  one-third  or  three-eighths  of 
the  original  twenty-four-hour  daily  dose.  The  belladonna 
mixture  is  still  continued,  and  ten  hours  after  the  second  dose 
of  morphin,  i.e.,  about  the  twenty-eighth  hour,  3  to  5  com- 
pound cathartic  pills  are  given  again,  and  5  grains  (0.32  Gm.) 
of  blue  mass ;  if  necessary,  six  or  eight  hours  later  a  saline  is 
given. 

When  a  thorough  action  of  the  bowels  has  again  been  ob- 
tained, at  about  the  thirty-sixth  hour,  a  third  dose  of  morphin 
is  given,  which  is  one-sixth  or  three-sixteenths  of  the  original 
dose.  This  is  usually  the  last  dose  of  morphin  that  is 
necessary. 

Again,  ten  hours  after  this  third  dose  of  morphin,  i.e.,  the 
forty-sixth  hour,  3  to  5  cathartic  pills  and  5  grains  (0.32  Gm.) 
of  blue  mass  are  again  repeated,  followed  in  seven  or  eight 
hours  by  a  saline,  and  by  this  time  the  stools  should  appear 
green. 


OPIUM    POISONING.  437 

After  the  stools  have  become  green,  and  the  bowels  thor- 
oughly evacuated,  about  eighteen  hours  after  the  third  dose  of 
morphin,  2  ounces  (60  milsj  of  castor  oil  should  be  given. 
It  may  be  necessary  to  continue  the  belladonna  mixture  for 
one  or  two  further  cathartic  periods  before  the  green  stools 
appear.  During  this  last  period,  when  the  bowels  are  moving, 
and  before  the  castor  oil  is  given,  the  patient  suffers  the 
greatest  discomfort.  The  nervousness  and  discomfort  can  be 
controlled  by  codein  in  3-  (0.195  Gm.)  to  5-  grain  (0.32  Gm.) 
doses  hypodermically. 

About  the  thirtieth  hour  these  patients  should  be  given 
strychnin  or  digitalis,  or  both.  Later,  tonics,  such  as  iron, 
arsenic,  or  phosphorus,  are  indicated.  During  this  treat- 
ment light  nourishing  food  is  given.  After  the  system  is  rid 
of  the  morphin  there  is  danger  of  the  patient  over-eating, 
thus  bringing  back  symptoms  similar  to  those  of  the  with- 
drawal period,  and  due  to  indigestion.  The  patient  naturally 
assigns  the  cause  of  these  symptoms  to  the  discontinuance  of 
the  drug,  rather  than  to  the  true  cause,  namely,  that  of  over- 
eating. 

If,  as  occurs  at  times,  about  the  thirty-sixth  hour,  the 
stools  become  clay-colored,  some  form  of  ox-gall  in  small 
doses,  repeated  every  two  or  three  hours,  is  effective  in  bring- 
ing about  the  free  flow  of  bile.  At  times  it  may  be  necessary 
to  continue  the  morphin  through  the  fourth  period. 

Codein  and  dionin  are  preferable  to  heroin  to  act  as  carry- 
ing-over drugs.  If  the  patient  shows  an  idiosyncrasy  for  one 
form  of  opium,  another  salt  should  be  tried. 

The  after-treatment  is  very  important.  This  interval 
should  be  fully  occupied,  preferably  in  the  open  air,  with 
plenty  of  exercise,  if  not  with  a  course  of  physical  training. 
Unless  this  is  done  the  patient  may  become  a  neurasthenic  or 
drift  back  into  the  old  habits. 

The  mental  state  of  the  patient  will  subsequently  have  to 
be  improved,  otherwise  he  will  be  readily  discouraged.  Exer- 
cise and  encouragement  will  soon  change  the  depressed  and 
irritable  patient,  under  treatment  for  the  opium  habit,  to 
one  with  good  spirits  and  normal  health. 


438  THE   INTOXICATIONS. 

ALCOHOLISM. 

The  treatment  of  alcoholic  subjects  must  be  considered 
under  the  three  separate  headings  of  Acute  Alcoholism, 
Chronic  Alcoholism,  and  Alcoholism  with  Symptoms  of 
Delirium  Tremens. 

When  alcohol  in  some  form  has  been  consumed  for  the 
first  time  by  those  unaccustomed  to  its  use  it  not  infrequently 
produces  alarming-  symptoms.  Severe  nausea,  retching  and 
vomiting,  diarrhea,  and  finally  collapse  or  disordered  mental 
conditions  are  prominent  symptoms,  directly  due  to  the 
eflrects  of  alcohol.  During  the  subsidence  of  the  attack,  gas- 
tritis or  nephritis  may  complicate  the  condition.  Alcoholic 
beverages  have  been  taken  accidentally  by  children,  who  as  a 
result  have  suffered  severe  attacks  of  acute  alcoholism. 

TREATMENT  OF  ACUTE  ALCOHOLISM. 

All  efforts  are  directed  toward  the  elimination  of  the 
alcohol.  An  emetic  by  mouth,  or  apomorphin  hypodermic- 
ally,  is  indicated,  especially  if  the  patient  is  too  ill  to  have 
gastric  lavage.  The  bowels  should  be  thoroughly  evacuated, 
either  by  calomel  in  divided  doses  or  by  an  enema.  The  skin 
should  be  rendered  active  by  bathing,  sweating,  and  the  inges- 
tion of  large  quantities  of  water. 

Sleep  and  quiet  should  be  obtained  for  the  patient,  using 
chloral  and  the  bromids,  veronal  or  trional  in  full  doses.  It 
may  be  necessary  to  resort  to  the  use  of  morphin  hypoder- 
mically,  or  to  an  opium  suppository. 

The  diet  should  be  light  and  nourishing,  preferably  milk 
and  broth,  until  the  acute  inflammatory  condition  of  the  gas- 
tro-intestinal  tract  has  subsided.  Alcoholic  beverages  are  con- 
traindicated.  If  depression  is  marked,  hypodermic  injections 
of  strychnin  sulphate,  to  be  repeated  as  conditions  warrant, 
are  useful. 

TREATMENT    OF     CHRONIC    ALCOHOLISM. 

This  very  familiar  condition  in  some  form  is  a  problem 
constantly  confronting  physicians,  police  departments,  and 
civil  courts.  Slowly  public  opinion  is  awakening  to  the  fact 
that  drunkenness  is  often  but  an  incident  in  a  life  of  misfor- 


ALCOHOLISM.  439 

tune,  and  that  jail  and  punishment  are  not  remedies  that  will 
cure  this  type  of  slow  poisoning-  by  alcohol. 

The  treatment  should  be  directed  toward  the  elimination 
of  the  poison,  and  discovering-  and  solving  the  underlying 
social  problem  that  presents  itself. 

Lambert  has  found  the  following  treatment  very  satis- 
factory : — 

IJ  Tincturse  belladonnc-e  (15%)   ....   fSij   (7.50  mils). 
Fluidextracti  hyoscyami, 
Fluidextracti  xanthoxyli   aa  fSj   (3.75  mils). 

This  mixture  is  given  every  hour  of  the  day  and  night 
beginning  with  6-drop  doses  (0.4  mil)  and  increasing  2  drops 
(0.13  mil)  at  the  end  of  every  six  hours  until  the  patient  is 
taking  16  drops  (1.0  mil),  or  until  dryness  of  the  throat,  dila- 
tion of  the  pupils,  or  a  belladonna  rash  shows  that  the  patient 
has  reached  the  limits  of  tolerance. 

Some  patients  can  take  but  little  of  this  mixture,  1  or  2 
drops  (0.07  to  0.13  mil)  every  hour,  but  as  long  as  they  obtain 
the  full  physiologic  effects,  as  judg'ed  by  symptoms  of  bella- 
donna intolerance,  the  desired  result  is  achieved. 

With  the  first  6  drops  (0.4  mil)  of  this  mixture  from  2  to 
5  compound  cathartic  pills  and  5  grains  (0.32  Gm.)  of  blue 
mass  are  also  given.  Five  to  six  hours  later  a  saline  is  given. 
At  about  the  eighteenth  to  the  twentieth  dose  of  the  bella- 
donna mixture  there  are  also  given  3  to  5  compound  cathartic 
pills,  with  5  grains  (0.32  Gm.)  of  blue  mass,  followed  by  a 
saline  five  hours  later ;  and  again  at  about  the  thirtieth  dose 
and  the  forty-second  dose  the  pills  and  the  blue  mass  are 
again  repeated. 

Often,  when  these  last  cathartics  act,  green  bilious  stools 
will  appear,  and  1  or  2  ounces  (30  to  60  mils)  of  castor  oil 
should  be  given,  and  the  treatment  stopped.  Sometimes  it  is 
necessary  to  push  the  belladonna  higher  than  16  drops  to  get 
the  symptoms  of  full  tolerance,  and  to  obtain  the  biliary 
reaction. 

At  times  it  is  necessary  to  carry  this  belladonna  treatment 
over  the  sixtieth  or  even  into  the  seventieth  hour,  with  extra 
dosag'e  of  cathartics  every  twelve  hours  as  above. 

In  young  and  vigorous  patients,  the  alcohol  can  be  imme- 
diately   withdrawn.      As    a   general    rule,    to    the    older    and 


440  THE   INTOXICATIONS. 

nervous  patients,  who  have  been  on  a  prolonged  debauch,  it 
is  necessary  to  give  2  ounces  (60  mils)  of  whisky  four  or  five 
times  during  the  first  twenty-four  hours.  Strychnin  and 
digitalis  are  indicated  in  this  class  of  cases.  Chloral  hydrate 
and  morphin  are  useful  in  producing  sleep. 

If  the  patient  has  alcoholic  gastritis,  is  nauseated  and  can- 
not retain  his  medicine,  10  to  20  grains  (0.66  to  1.3  Gm.)  of 
sodium  bicarbonate  or  sodium  citrate  every  hour  for  five  or 
six  doses  has  been  very  useful.  In  severer  cases,  the  addition 
of  5  grains  (0.32  Gm.)  of  Tully's  powder  (pulvis  morphinse 
compositus)  at  four-hour  intervals,  for  two  or  three  doses,  is 
beneficial.  Often  the  sodium  citrate  can  be  given  with  10  to 
20  grains  (0.66  to  1.3  Gm.)  of  cerium  oxalate  some  hours  after 
the  Tully's  powder  has  been  discontinued. 

If  delirium  tremens  develops  during  or  following  the 
treatment,  it  may  be  necessary  to  keep  the  patient  asleep  with 
hypnotics,  giving  cathartics  once  in  twenty-four  hours,  and 
abundant  nourishing  food,  as  milk  and  eggs. 

If  the  milk  does  not  agree  with  patients  who  are  taking  the 
belladonna  mixture,  a  light  diet  of  eggs,  broths,  bread  and 
butter,  or  a  small  amount  of  meat  and  vegetables  can  be 
substituted. 

Chronic  alcoholism  is  being  treated  in  various  private  insti- 
tutions throughout  the  country  more  or  less  upon  the  prin- 
ciples governing  the  foregoing  treatment.  Unfortunately,  the 
poorer  classes,  who  suffer  from  the  continued  effects  of  alco- 
holic poisoning,  are  in  no  position  to  receive  this  thorough 
treatment.  It  is  incumbent  upon  the  public  to  establish,  in 
connection  with  municipal  hospitals,  provision  for  the  treat- 
ment of  chronic  alcoholics,  as  those  suffering  from  disease  and 
not  as  criminals. 

TREATMENT    OF    DELIRIUM    TREMENS. 

Delirium  tremens  is  a  condition  brought  about  as  the 
result  of  chronic  alcoholism.  It  is  not  dependent  upon  the 
amount  of  alcohol  taken,  as  many  men  who  have  never  been 
intoxicated,  but  who  have  been  continuous  users  of  alcohol  for 
years,  when  confined  to  bed  on  account  of  severe  illness,  or 
accident,  have  suddenly  developed  mania  a  potu. 


ALCOHOLISM.  441 

The  treatment  is  largely  symptomatic.  The  prognosis  is 
dependent  upon  the  condition  of  the  various  organs  of  the 
body,  and  upon  the  severity  of  the  associated  condition,  such 
as  an  acute  infection  or  fracture.  A  subject  of  chronic  alco- 
holism usually  shows  disease  of  the  cardiovascular  and  the 
renal  system,  and  treatment  is  aimed  at  rendering  as  efficient 
as  possible  these  vital  organs. 

Authorities  differ  as  to  the  withdrawal  of  alcohol  in  victims 
of  delirium  tremens,  but  as  a  general  rule  it  is  advisable  abso- 
lutely to  forbid  alcohol  in  the  young  and  healthy  patient,  and 
in  the  weak  and  elderly  to  reduce  slowly  the  amount  taken. 

The  supportive  measures  are  of  first  importance.  The 
degenerated  heart-muscle  should  be  stimulated  with  hypo- 
dermics of  strychnin,  caffein,  or  digitalis. 

Elimination  by  means  of  vigorous  purgatives  must  be 
obtained  by  the  administration  of  compound  cathartic  pills, 
blue  mass,  calomel,  or  a  pill  containing  calomel  powder, 
squills,  and  powdered  digitalis,  of  each  1  grain  (0.065  Gm.). 

The  skin  should  be  rendered  active  by  placing  the  patient 
in  a  warm  bath ;  if  delirious,  this  form  of  hydrotherapy  con- 
tinued for  several  hours  under  constant  supervision,  affords  a 
great  deal  of  relief. 

An  abundance  of  water  should  be  given  by  mouth,  by 
bowel,  or  by  hypodermoclysis  in  the  form  of  salt  solution,  for 
by  this  procedure  the  toxemia  is  decreased,  and  the  skin  and 
kidneys  are  stimulated  to  greater  activity. 

Emesis  is  contraindicated  in  the  feeble  and  elderly,  and  in 
the  state  of  delirium  tremens  it  is  of  questionable  value. 

Often  in  the  severest  cases  of  young  vigorous  individuals 
apomorphin  hypodermically  %o  grain  (0.0065  Gm.)  produces 
vomiting  early,  followed  by  a  period  of  quiet,  if  not  sleep. 

Rest  for  the  patient  is  extremely  difficult  to  obtain. 
Paraldehyd,  in  doses  of  from  1  to  2  drams,  (4  to  8  mils),  to 
be  repeated  in  an  hour,  is  valuable  in  producing  a  sleep,  from 
which  the  patient  may  awaken  either  refreshed  and  clear- 
minded  or  with  the  delirium  much  lessened. 

Chloral  trional,  veronal,  sulphonal,  medinal,  and  other 
hypnotics  are  useful  in  mild  cases.  Hyoscin  Y^qq  grain 
(0.00065  Gm.)  and  morphin  have  to  be  resorted  to,  to  secure 
quiet  in  those  with  motor  symptoms. 


442  THE   INTOXICATIONS. 

Chloral  and  morphin  combined  act  very  efficaciously.  A 
combination  of  chloral  and  the  bromids  are  useful  in  mild 
cases. 

Hypnotics  do  not  necessarily  cut  short  the  delirium,  but 
they  act  by  securing  rest  for  the  patient. 

Lambert  has  used  with  success  ergot  hypodermically  in 
Livingston's  solution,  which  is  as  follows:  One  dram  (3.9 
Cms.)  ofi  solid  extract  of  ergot  is  dissolved  in  an  ounce 
(30  mils)  of  sterile  water,  and  3  drops  (0.2  mil)  of  chloroform 
and  3  grains  (0.195  Gm.)  of  chloretone  are  added,  and  the 
solution  filtered ;  this  is  sterile,  and  can  be  given  directly  into 
the  muscles  in  gluteal  region  or  into  the  deltoid. 

It  should  not  be  given  subcutaneously,  as  it  produces  great 
pain.  The  administration  every  two  to  four  hours  reduces  the 
dilated  blood-vessels,  lessens  the  various  congestions,  and 
brings  about  a  better  equilibrium  of  the  circulation.  After  its 
administration,  there  is  a  tendency  to  a  quieter  delirium,  and 
less  need  of  restraint. 

As  soon  as  possible  nourishing  food  should  be  given  in  the 
form  of  milk,  eggs  and  milk,  or  broths. 

The  patient  should  be  confined  to  bed  while  in  a  delirious 
state.  A  sheet  folded  and  extending  across  the  chest,  with  the 
wrist  and  ankle  shackles,  is  a  better  means  of  restraint  than 
a  straight,  rigid  jacket  extending  the  greater  length  of  the 
body,  and  thereby  preventing  the  radiation  of  heat. 

During  convalescence,  bitter  tonics  are  indicated  in  the 
form  of  capsicum,  gentian,  and  nux  vomica. 

Exercise  in  moderation,  fresh  air,  and  the  proper  amount 
of  sleep  are  essential  in  the  restoration  to  health,  which  can- 
not be  complete  without  total  abstinence  from  alcohol. 

Methyl  Alcohol.  Wood  alcohol,  Columbian,  colonial, 
union  or  eagle  spirits. 

The  ingestion  of  2  drams  (7.5  mils)  has.  been  followed  by 
blindness;  in  other  individuals  1  ounce  (30  mils)  produced 
only  intoxication.  Another  curious  condition  is  that  symp- 
toms may  be  delayed  twenty-four  hours. 

The  general  treatment  consists  of  prompt  gastric  lavage, 
vigorous  stimulation  by  strychnin,  camphor,  and  digitalis 
hypodermically,  saline  irrigation  by  the  bowel,  free  sweating 
and  the  use  of  emetics. 


FOOD    POISONING.  443 

The  optic  nerve  atrophy,  which  is  a  common  result  in 
those  convalescent  from  the  effects  of  methyl  alcohol  poison- 
ing', is  treated  by  pilocarpin,  sweat-baths,  and  the  use  of 
iodids,  although  recovery  from  the  grave  accident  cannot  be 
counted  upon  in  many  instances.  Strychnin  in  lart^e  doses 
later  seems  to  limit  the  extension  of  secondary  optic  nerve 
atrophy. 

FOOD    POISONING. 

The  success  of  the  treatment  in  food  poisoning-  must 
necessarily  depend  here,  as  in  all  conditions,  upon  the  recog- 
nition of  the  cause. 

Certain  general  principles  govern,  and  are  applicable  to, 
all  forms  of  food  poisoning.  It  is  very  difficult  at  times  to 
determine  the  cause  of  an  illness,  as  to  whether  the  origin 
lies  in  poisoned  food,  or  is  due  to  bacterial  infections  and 
intoxications. 

The  treatment  consists  in  the  use  of  prophylactic,  S3^mp- 
tomatic  and  eliminative  measures. 

Prophylactic  measures,  such  as  the  inspection  of  cattle  for 
diseased  conditions  prior  to  killing,  examination  of  the  meat 
after  it  is  dressed,  inquiry  into  the  sanitary  conditions  of  the 
slaughter-house  and  its  employees,  and  the  subsequent  stor- 
ing and  preparation  for  eating,  are  the  best  safeguards  against 
meat  poisoning. 

Bacteria  may  be  destroyed  in  the  process  of  cooking,  but 
this,  of  course,  cannot  be  relied  upon  to  destroy  products  of 
chemical  changes. 

Abdominal  pain  is  usually  a  prominent  symptom  of 
ptomain  poisoning.  Locally,  heat  or  cold,  preferably  the 
former,  and  counter-irritation  by  means  of  a  turpentine  stupe 
or  a  mustard  plaster  are  useful.  After  the  bowels  have  been 
thoroughly  emptied  by  castor  oil,  or  a  mercurial  followed  by 
a  saline,  if  the  abdominal  pain  persists,  small  doses  of  an 
opiate  may  be  required. 

High  colonic  irrigation  with  warm  normal  salt  solution, 
allowing  6  to  8  ounces  (180  to  240  mils)  to  remain  in  the  colon, 
should  be  given  in  every  case  with  more  than  moderate  severe 
symptoms. 

If  considerable  retching  and  vomiting  occur,  washing  out 
the  stomach  tends  to  relieve  this  symptom. 


444  THE   INTOXICATIONS. 

Food  should  be  restricted  for  at  least  twenty-four  or  forty- 
eight  hours  following  the  onset  of  symptoms,  and  with  the 
beginning  of  improvement  of  the  patient's  condition  liquid 
diet  in  small  quantities,  at  short  intervals,  can  be  given. 
Usually  the  patient  does  not  complain  of  the  lack  of  food. 
The  most  suitable  foods  are  milk  and  albumin  water,  increas- 
ing to  semi-solid  food  as  the  gastro-intestinal  symptoms 
subside. 

If  the  patient  is  very  much  prostrated,  or  if  collapse  occurs 
during  the  acute  symptoms,  the  use  of  stimulants,  such  as 
atropin,  strychnin,  and  aromatic  spirits  of  ammonia  is 
indicated. 

The  serums  prepared  as  antidotes  for  bacterial  infection  of 
food,  particularly  for  meats,  have  been  used,  but  not  with  a 
great  degree  of  success. 

SUNSTROKE. 
(Thermic  Fever,  Insolation,  Heat  Exhaustion.) 

The  treatment  of  conditions  arising  from  the  exposure 
of  the  human  body  to  too  great  a  degree  of  heat,  regardless  of 
the  source,  is  entirely  preventible  when  rigid  prophylactic 
measures  are  practised.  Humidity  is  an  important  factor  in 
intensifying  the  effects  of  heat. 

Prophylaxis.  In  the  larger  cities  the  housing  conditions 
and  sanitation  have  helped  in  a  measure  to  reduce  the  mor- 
tality from  heatstroke,  especially  among  the  very  young 
and  the  aged.  A  further  degree  of  success  has  been  attained 
by  moving  the  city  children  to  the  country  and  seashore,  so 
as  to  enjoy  the  better  air  of  such  environments.  The  value 
of  public  parks  and  city  squares  is  being  more  appreciated 
for  the  benefit  of  children  during  the  hot  weather. 

In  countries  with  a  more  or  less  uniform  hot  climate  the 
number  of  fatalities  from  the  heat  is  not  so  great  as  in  the 
United  States,  where  temperature  variations  are  extreme. 
People  have  learned  the  value  of  prophylaxis.  Public  demon- 
strations and  gatherings  are  avoided  during  the  warm  hours 
of  the  day.  Marches  and  parades  are  dispensed  with,  and 
cool  spots  are  sought.  All  living  and  working  rooms  should 
be  well  ventilated,  if  necessary  artificially  changing  the  air, 


SUNSTROKE.  445 

which  can  also  be  cooled  by  such  a  means.  Every  effort 
should  be  directed  to  lessen  the  individual's  exposure,  and  to 
increase  his  resistance  to  the  heat. 

Proper  clothing  is  essential,  if  exposure  to  the  heat  is 
necessary.  Suitably  fitting  straw  hats,  well  ventilated,  and 
constructed  so  that  moist  sponges  or  cloths  may  be  carried 
therein,  should  be  worn.  Paradoxical  as  it  may  seem,  flannel, 
light  in  weight,  is  the  best  material  for  summer  wear.  This 
material  protects  from  extreme  heat,  and  at  the  same  time  in- 
creases the  radiation  of  body  heat.  Clothing  should  be  loose 
fitting.  Bathing  should  be  frequent,  for  the  sake  of  cleanliness 
and  for  stimulatory  effect  upon  the  body,  which  counteracts 
the  depression  resulting  from  excessive  degrees  of  heat. 

Moderation  in  all  things  is  well  applied  to  the  mode  of 
living  in  hot  weather.  Alcohol  is  to  be  avoided,  except  for 
those  to  whom  because  of  long  usage  it  is  a  necessity. 

Physical  or  mental  work  should  be  limited.  As  radiation 
progresses  much  fluid  is  lost  by  perspiration,  and  it  is  essen- 
tial that  large  quantities  of  fluid  be  taken  to  replace  this  loss. 
Ice-cooled  water  is  better  than  iced  water.  Fruit  juices  may 
be  added  to  carbonated  water,  and  served  as  a  good  substitute 
for  plain  water.  Iced  tea  and  coffee  are  recommended  for 
those  taking  these  beverages  daily. 

The  diet  should  be  moderate  in  amount,  with  small 
amounts  of  carbohydrate  and  fat.  Fruit  and  vegetables  in 
abundance  are  most  useful. 

Constipation  must  be  guarded  against  by  taking  plenty  of 
water,  fruits,  vegetables  and  laxatives  if  necessary.  Diarrhea 
calls  for  physical  rest,  and  the  limitation  of  or  abstinence  from 
food  for  a  short  period. 

TREATMENT. 

The  symptoms  divide  the  patients  into  two  classes:  first, 
those  with  thermic  fever,  usually  hyperpyrexia;  and  second, 
heat  exhaustion  (subnormal  temperature),  and  presenting 
symptoms  referable  to  the  nervous  system. 

In  the  condition  of  hyperpyrexia  the  indication  is  to  re-- 
duce  without  delay  the  temperature,  which  in  itself  is  fatal  if 
not  controlled. 


446  THE   INTOXICATIONS. 

For  this  purpose,  ice  water  enemata,  ice  rubs,  ice  water  tub 
baths,  and  ice  packs  are  used.  The  method  most  readily 
available  should  be  used.  Drugs  that  increase  cerebral  con- 
gestion and  those  that  stimulate  the  functions  of  the  body  are 
contraindicated.  If  hyperpyrexia  does  not  exist,  the  milder 
hydrotherapeutic  measures  may  be  applied.  In  all  forms  of 
treatment  directed  toward  lowering  the  temperature,  it  is  im- 
portant to  take  the  temperature  by  rectum  during  the  treat- 
ment. This  temperature  must  not  be  allowed  to  become  lower 
than  100°  F.  (37.8°  C),  and  treatment  must  be  discontinued 
when  this  point  is  approached. 

The  cases  of  heat  exhaustion  referred  to  as  being  charac- 
terized by  nervous  symptoms  are  treated  by  stimulants. 
Strychnin,  caffein,  and  atropin  are  to  be  given  hypodermic- 
ally  for  their  effects  on  the  vital  centers,  vasomotor,  cardiac 
and  respiratory.  Rapidly  acting  dififusible  stimulants  by 
mouth,  such  as  alcohol,  aromatic  spirits  of  ammonia,  spirits 
of  camphor,  and  Hoffman's  anodyne  have  a  rapid  beneficial 
effect.  Oxygen  inhalation  and  artificial  respiration  are  indi- 
cated if  symptoms  of  respiratory  failure  are  manifest. 

If  dilatation  of  right  heart  is  present,  venesection  is  de- 
manded to  relieve  the  venous  congestion  consequent  to  this 
emergency.  Light  massage  of  the  extremities  aids  in  equaliz- 
ing the  distribution  of  the  blood.  If  the  temperature  continues 
subnormal,  external  heat  is  indicated. 

Although  a  patient  may  survive  a  severe  attack  of  sun- 
stroke, in  a  large  percentage  of  cases  the  subject  is  never  re- 
stored to  his  original  health. 

Intolerance  of  heat,  even  a  mild  degree  thereof,  is  a  com- 
mon after-complaint,  and  removal  of  the  patient  to  a  cooler 
climate  is  indicated.  Frequently  various  cerebral  conditions 
are  complained  of,  and  physical  disturbances,  such  as  loss  of 
memory,  irritability,  insomnia,  mental  hebetude,  and  dementia 
are  not  uncommon. 

Convalescents  should  be  closely  guarded  in  order  to  pre- 
vent suicidal  attacks.  The  after-care  is  difficult,  and  presents 
conditions  not  unlike  those  noted  in  illuminating-gas  poison- 
ing (q.v.). 


Diseases  of  Metabolism  and 
Nutrition 


BY 

CLIFFORD    B.    FARR,    A.M.,    M.D., 

Associate  in  Medicine,  University  of  Pennsylvania,  Pliiladelphia; 
Assistant  Visiting  Physician,  Philadelphia  General  Hospital;  Pro- 
fessor of  Diseases  of  the  Stomach  and  Intestines,  Philadelphia 
Polyclinic;   Formerly  Pathologist,  Presbyterian  Hospital, 

AND 

RALPH    PEMBERTON,    M.S.,    M.D., 
Physician  to  the  Presbyterian  Hospital,  Philadelphia. 


(447) 


Diseases  of  Metabolism  and 
Nutrition. 


FOREWORD. 

In  the  section  on  Diseases  of  Metabolism  an  endeavor  has 
been  made  to  embody  the  fundamental  facts  and  theories  in  a 
preliminary  chapter  to  which  have  been  appended  useful  dietetic 
tables.  In  the  articles  on  the  individual  diseases  the  etiology, 
physiologic  chemistry  and  symptoms  have  been  considered  with 
sufficient  fullness  to  serve  as  a  guide  to  treatment.  The  medici- 
nal treatment  of  these  affections  offers  little  that  is  novel,  so  that 
the  effort  has  been  to  make  a  rational  selection  of  well-known 
remedies.  The  prophylactic  treatment  and  general  management 
have  been  more  fully  considered,  and  no  pains  have  been  spared 
to  make  the  dietetic  treatment  as  explicit  as  possible.  In  Obesity 
caloric  diets  have  been  worked  out,  while  in  Diabetes  the  useful 
tables  of  Janeway  and  Joslin  (Allen  treatment)  have  been  intro- 
duced. In  the  discussion  of  Scurvy  the  importance  of  vitamins 
has  been  emphasized ;  while  under  the  caption  of  Chronic  Arthri- 
tis, the  newer  dietetic  methods  have  been  explained. 

GENERAL    CONSIDERATIONS. 

The  intelligent  treatment  of  the  constitutional  affections  re- 
quires not  only  a  knowledge  of  the  pathology  and  symptomatology 
of  the  various  diseases  and  syndromes,  but  also  a  clear  concep- 
tion of  the  underlying  principles  of  metabolism. i  It  will  be  con- 
venient to  discuss  the  latter  division  of  our  subject  in  a  prelimi- 
nary chapter.  This  will  allow  of  a  briefer  discussion  of  chemical 
pathology  in  the  chapters  on  the  individual  diseases.  It  will  also 
permit  us  to  introduce  a,  few  observations  on  general  dietetics. 

Definition.  Metabolism  is  the  name  applied  to  those  phys- 
ical and  chemical  processes  occurring  within  the  living  body, 
by  means  of  which  heat  and  energy  are  liberated,  and  nutriment 
is  assimilated  and  built  up  into  living  structures ;  or,  on  the  other 
hand,  effete  tissues  and  waste  products  are  broken  down  and 
excreted  from  the  body.  The  term  is  not  applicable  to  changes 
in  the  food,  which  occur  in  the  stomach  and  intestines  before 
absorption,  or  to  alterations  in  the  secretions  and  excretions  after 

29  (449) 


450       DISEASES    OF   METABOLISM    AND    NUTRITION. 

they  have  escaped  from  the  glands  of  the  skin,  kidney  and  gas- 
trointestinal tract,  or  from  tlie  alveolar  epithelium  of  the  lung.*^ 
Proteins.  The  principal  substances  which  furnish  heat  and 
energ}'^  are  the  proteins,  hydrocarbons  and  carbohydrates.  Pro- 
teins also  serve  to  renew  the  body  cells,  while  fat  and  glycogen 
are  stored  as  an  energy  reserve.  In  addition  to  these  principal 
foodstuffs  there  are  important  mineral  salts  and  peculiar  sub- 
stances known  as  vitamins.  Water  and  oxygen,  although  not 
foodstuffs,  are  of  equal  importance  in  the  chemical  processes, 
and  are  utilized,  the  latter  particularly,  in  definite;  or  even  quan- 
titative amounts.  The  proteins  differ  from  the  other  important 
foodstuffs,  in  that  they  invariably  contain  nitrogen  in  addition  to 
carbon,  hydrogen  and  oxygen.  The  various  proteins  also  contain 
other  important  elements,  such  as  iron,  sulphur,  phosphorus  and 
iodin.  Chemically  they  are  very  complex  substances,  frequently 
containing  a  large  number  of  atoms  in  the  molecule.  As  these 
molecules  are  capable  of  an  almost  infinite  variation  in  their  in- 
ternal arrangement,  the  possible  combinations  are  enormous.  Ac- 
cording to  tlie  modern  conception,  each  protein  molecule  is  made 
up  of  a  comparatively  large  number  of  complicated  substances, 
known  as  amino-acids,  loosely  bound  together.  During  digestion 
and  assimilation,  proteins  are  broken  down  into  their  constituent 
amino-acids,  and  are  afterward  built  up  into  the  particular  forms 
required  by  the  individual.  It  therefore  makes  little  difference 
in  what  form  protein  is  ingested,  provided  a  sufficient  number  of 
amino-acids  are  furnished.  Gelatin,  which  closely  resembles  pro- 
tein, is  inefficient  as  a  foodstuff,  because  it  lacks  certain  essential 
amino-acids.  The  proteins  of  meat,  fish,  eggs  and  milk  are  simi- 
larly superior  to  those  of  wheat,  beans  and  Indian  corn.  A  wide 
selection  of  vegetable  proteins  will,  however,  furnish  all  the  neces- 
sary elements  of  the  diet.  The  amino-acids  are  often  spoken  of  as 
"building  stones,"  probably  in  allusion  to  the  toy  building  stones 
with  which  such  a  multiplicity  of  structures  can  be  erected.  The 
principal  "building  stones"  are  glycocoll,  alanin,  valin,  leucin,  pro- 
lin,  phenylalanin,  aspartic  acid,  glutamic  acid,  serin,  cystin,  tyro- 
sin,  lysin,  histidin,  arginin  and  tryptophan.  The  daily  require- 
ment of  protein  is  approximately  1  gram  (15  grs.)  for  each 
kilogram  (2.2  lbs.)  of  body  weig'ht.f     This,  according  to  Tay- 


*  Slightly  modified  from  Farr :     Medicine  for  Nurses,  Philadelphia,  1915. 
t  It  is  convenient  to  use  the  metric  system  in   estimating  calories 
even  if  we  afterwards  convert  our  results  into  ordinary  measures. 


GENERAL   CONSIDERATIONS.  451 

lor,^  gives  100  per  cent,  margin,  although  at  least  50  per  cent. 
less  than  the  old  empiric  standards,  which  were  based  on  a 
study  of  the  diets  actually  employed  by  Europeans.  A  still 
further  reduction  is  admissible,  if  necessitated  by  impairment 
of  the  excretory  functions. 

Only  a  small  amount  of  the  protein  is  actually  used  for  growth 
and  reconstruction ;  the  remainder  is  split  up  into  sugar  and  a  ni- 
trogenous fraction,  and  dius  becomes  available  for  the  production 
of  energy.  Most  of  the  nitrogen  is  eliminated  as  urea,  which  still 
has  a  certain  caloric  value,  so  that  the  heat  value  of  protein,  which 
is  theoretically  5.7,  is  actually  only  4.  The  utilization  of  protein 
seems,  in  itself,  to  require  a  large  amount  of  energy,  so  that  at 
least  25  per  cent,  of  the  remaining  calories  are  lost,  i.e.,  they  are 
given  off  as  external  heat  (specific  dynamic  factor  of  protein). 
In  contrast  to  protein,  carbohydrates  and  hydrocarbons  are  com- 
pletely oxidized  to  COo  and  H2O,  and  eliminated  through  the 
lungs.  The  specific  dynamic  factor  for  carbohydrates  is  stated  as 
6  per  cent.,  and  for  hydrocarbons  as  12  per  cent.  (Taylor).  It  is 
readily  seen,  therefore,  that  protein  is  not  an  economic  food  for 
the  production  of  heat  and  energy. 

The  major  portion  (approximately  80  per  cent.)  of  the  nitro- 
gen elimination  in  the  urine  is  in  the  form  of  urea,  the  remainder 
appearing  as  creatinin,  uric  acid  and  purins.  The  creatinin  excre- 
tion varies  directly  in  proportion  to  the  catabolism  of  muscular 
tissue,  and  is  practically  a  fixed  amount  for  each  individual.  The 
uric  acid  and  purins  are  also  dependent  on  a  special  form  of  cata- 
bolism, that  of  nucleic  acid.  They  are  derived  from  the  breaking 
down  of  the  nuclei  of  the  fixed  and  wandering  cells  (leucocytes) 
of  the  body  (endogenous  fraction),  or  from  the  catabolism  of  sim- 
ilar cells  introduced  with  the  food  (exogenous  fraction)  ;  the  latter 
fraction  can  be  eliminated  by  a  purin-free  diet,  the  former  cannot. 

These  nitrogenous  substances,  including  urea  and  the  other 
non-protein  bodies,  are  carried  to  the  kidneys,  and  there  largely 
eliminated.  The  ingestion  of  nitrogen  in  the  food  is  almost  bal- 
anced by  its  excretion  in  the  urine.  The  difference,  which  amounts 
to  1  or  2  grams  (15  or  30  grs.),  is  eliminated  to  a  slight  degree 
through  the  skin,  but  more  largely  through  the  intestines.  The 
blood  ordinarily  contains  25  to  30  milligrams  of  total  non- 
protein nitrogen  per  100  mils.*  ■*    Approximately  one-half  of  this 

*  In  nephritis,  with  or  without  uremia,  the  total  non-protein  nitrogen 
may  be  enormously  increased  (70,  150,  180  milHgrams  or  more  per  100 
mils). 


452       DISEASES    OF    METABOLISM    AND    NUTRITION. 

amount  consists  of  urea.  -The  balance  comprises,  in  addition  to 
excretory  products,  newly  absorbed  amino-acids  on  their  way  to 
utilization.  Normal  blood  (purin-free  diet)  contains  from  0.5  to 
2.9  milligrams  of  uric  acid  per  100  grams,  or  an  average  of 
1.4  milligrams.*  In  the  early  part  of  an  attack  of  gout  this 
amount  may  be  considerably  increased,  while  subsequent  to  the 
attack  it  may  reach  subnormal  value. 

Hydrocarbons.  The  hydrocarbons,  which  include  the  fats 
and  oils,  are  composed  of  carbon,  hydrogen  and  oxygen. 
Chemically  they  are  the  glycerids  of  certain  fatty  acids,  and 
may  be  readily  split  up  into  glycerin,  stearic,  palmitic  and 
oleic  acids.  These  acids,  when  free,  unite  with  bases,  sodium, 
potassium,  calcium,  etc.,  to  form  soaps.  In  the  body  hydro- 
carbons are  normally  either  deposited  in  storage  depots  as  a 
reserve,  or  completely  split  up  into  CO2  and  HaO^  and,  as 
such,  eliminated  through  the  lungs.  Their  fuel  value  is  very 
high,  each  gram  (15  grs.)  yielding  9  calories.  If  present 
in  sufhcient  amount  they  are  utilized  for  the  production  of 
heat  and  energy  in  preference  to  protein,  and  hence  are 
described  as  "protein  sparing."  Carbohydrates,  however,  are 
still  more  readily  oxidized,  and  are  even  better  adapted  to  pre- 
serve the  protein  of  the  food  and  tissues  from  unnecessary 
combustion. 

Under  abnormal  conditions,  as  in  diabetes  or  starvation, 
the  fats  may  be  imperfectly  metabolized,  and  the  blood 
becomes  laden  with  betaoxybutyric  acid,  diacetic  acid  and 
acetone.  If  this  vice  of  metabolism  is  unchecked,  the  alka- 
linity of  the  blood  is  diminished,  and  the  condition  known 
as  acid  intoxication  is  induced.  In  order  to  neutralize  the 
acidity,  ammonia  split  off  from  the  nitrogenous  compounds 
combines  with  the  acids.  Under  these  conditions  there  is, 
therefore,  an  excess  of  ammonia  eliminated  in  the  urine. 
Therapeutically,  it  is  well  recognized  that  the  administration 
of  carbohydrates,  if  they  have  previously  been  withheld,  will 
often  overcome  this  complication  of  diabetes.  Sodium  bicar- 
bonate administered  by  the  mouth  or  intravenously  (3  to  5 
per  cent,  solution  in  water,  or  in  physiologic  saline  solution) 
is  sometimes  effective.    That  it  is  not  uniformly  so  is  good 


*  Folin's  method. 


GENERAL   CONSIDERATIONS.  453 

evidence  that  acidemia  presents  a  profound  disturbance  of 
metabolism,  not  a  simple  alteration  in  the  reaction  of  the 
blood.     (See  also  Diabetes.) 

Carbohydrates.  The  carbohydrates,  like  the  hydrocar- 
bons, consist  of  carbon,  hydrogen  and  oxygen,  but  the  hydro- 
gen and  oxygen  are  present  in  the  same  proportions  as  they 
are  found  in  water.  They  are  ingested  in  the  form  of  insolu- 
ble starches  (polysaccharids)  or  soluble  sugars  (monosac- 
charids  and  disaccharids).  Prior  to  absorption  they  are 
converted  into  the  monosaccharid  glucose.  Their  caloric 
values  vary  slightly,  but  for  clinical  purposes  the  factor  4  is 
sufficiently  accurate.  In  the  tissues  the  glucose  is  split  up 
or  oxidized  into  CO2  and  H2O,  as  in  the  case  of  the  hydro- 
carbons, or  is  stored  in  the  liver  and  muscles  as  animal 
starch,  or  glycogen.  The  glycogen  serves  as  a  reserve,  and 
is  always  immediately  available  for  the  production  of  energy. 
Hydrocarbons  and  carbohydrates  are  best  suited  to  furnish 
the  heat  and  energy  required  by  hard-working  men.  The  old, 
and  to  some  extent  still  the  popular  view,  was  that  such 
individuals  required  an  unusual  amount  of  meat  and  other 
proteins.  In  tropic  and  temperate  climates  carbohydrates 
form  the  preferable  source  of  energy.  In  the  Arctic  regions 
fats  are  preferred,  as  they  furnish  a  far  greater  proportion  of 
heat  than  other  foodstuffs,  bulk  for  bulk.  Under  normal  con- 
ditions little  or  no  sugar  escapes  in  the  urine,  although  the 
blood  usually  contains  approximately  0.1  per  cent,  of  sugar. 
As  long  as  starchy  food  alone  is  ingested,  the  normal  bounds 
are  not  exceeded,  but  even  in  normal  persons  the  ingestion 
of  a  large  amount  of  sugar  (100  to  200  Gms.)  may  increase 
the  percentage  in  the  blood  to  such  a  degree  that  glucose  will 
appear  in  the  urine  (limit  of  toleration).  The  secreting  epi- 
thelium of  the  kidney  holds  back  the  sugar  as  long  as  it  does 
not  exceed  a  certain  threshold  value  (0.14%).  Beyond  that 
value  it  is  freely  excreted.  In  some  diseases  of  the  pituitary 
and  thyroid  (hypopituitarism  and  hypothyroidism),  the  sugar 
toleration  is  increased,  while  in  diabetes  it  is  diminished. 
(For  theory  see  Diabetes.) 

Mineral  Salts.  A  large  assortment  of  mineral  salts  is 
required  for  growth  and  reconstruction,  but  these  do  not 
usually  have  to  be  especially  provided,  as  they  are  supplied 


454       DISEASES    OF   METABOLISM    AND    NUTRITION. 

in  excess  in  any  well-balanced  diet.  Occasionally  there  may 
be  a  deficienc}^,  as  of  iron  when  an  adult,  for  example,  is  kept 
for  a  long  time  on  a  pure-milk  diet.  The  same  is  true  of 
infants  if  an  exclusive  milk  diet  be  maintained  much  beyond 
the  usual  period  of  lactation.  In  other  instances — for  exam- 
ple, in  rickets — mineral  salts,  calcium  phosphate  and  carbo- 
nate may  be  present  in  abundance  in  the  diet,  but,  through 
same  fault  of  absorption  or  metabolism,  are  not  retained. 
The  most  important  salt,  quantitatively  at  least,  is  sodium 
chlorid.  Sodium  in  the  form  of  the  chlorid,  carbonate,  etc., 
is  present  in  the  blood  and  tissue-juices  to  the  extent  of  0.7 
per  cent.  Most  individuals  partake  of  an  excess  of  sodium 
chlorid,  which  is  quickly  eliminated  in  the  urine.  If  the 
excretory  power  of  the  kidney  be  impaired,  as  in  certain  forms 
of  nephritis  (parenchymatous),  the  salt  is  retained,  and  with 
it  sufficient  water  to  keep  it  in  physiologic  solution.  This  is 
believed,  therefore,  to  be  one  of  the  most  important  causes  of 
edema,  so  that  the  excessive  use  of  salt  may  be  far  from 
innocuous.  The  ordinary  foodstuffs,  with  the  addition  of 
merely  enough  sodium  chlorid  to  make  them  palatable,  will 
supply  as  much  of  this  substance  as  is  required  for  physio- 
logic needs.  In  addition  to  sodium  chlorid,  other  salts  of 
the  alkalies  and  alkaline  earths,  phosphates,  sulphates,  car- 
bonates, chlorids,  etc.,  of  sodium,  potassium,  ammonium,  cal- 
cium and  magnesium,  are  eliminated  in  greater  or  less  quan- 
tities in  the  urine.  The  following  table,  based  on  Folin's 
analyses  of  thirty  "normal"  urines,  shows  the  average  elimi- 
nation of  nitrogen,  and  of  various  important  salts  on  a  normal 
diet . 

Certain  substances,  some  of  which  contain  salts,  and  others 
which  are  dependent  for  their  activity  on  essential  oils,  etc., 
are  employed  in  the  diet  as  condiments.  Many  of  these  are 
absorbed  and  eliminated  through  the  kidneys  without  exert- 
ing any  distinct  effects  on  metabolism.  They  act  principally 
as  stimulants  to  the  secretions  of  the  stomach  and  intestines, 
and  secondarily,  in  some  instances,  as  gastrointestinal  and 
urinary  antiseptics. 

Vitamins.  In  recent  years  peculiar  bodies,  probably  of  a 
nitrogenous  nature,  which  have  a  profound  influence  on  nutri- 
tion  have  been  found  in  very  minute  amounts  in  certain  food- 


GExNERAL    CONSIDERATIOXS. 


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456        DISEASES    OF    METABOLISM    AND    NUTRITION. 

stuffs. "^  They  have  been  dubbed  vitamins.  Beriberi  has  long 
been  attributed  to  an  exclusive  diet  of  rice,  but  only  v^ithin 
recent  years  has  it  been  known  that  this  affection  could  be 
avoided,  or  even  cured  by  the  use  of  unpolished — that  is, 
unmilled— rice.  The  process  of  milling,  if  carried  too  far, 
removes  the  brownish  covering  (pericarp)  which  contains  the 
prophylactic  substance.  This  substance  may  be  extracted 
from  the  refuse,  and  administered  with  curative  effect.  Beri- 
beri is,  therefore,  in  part  at  least,  a  deprivation  disease.  In 
scurvy  the  lack  of  fresh  food — meat,  vegetables  or  fruit- 
juices — is  responsible  for  a  similar  state  of  affairs.  For  more 
than  a  century  scurvy  has  been  banished  from  the  British  and 
other  navies,  by  the  addition  of  lime-juice  to  the  old  dietary 
of  ship's  biscuit,  "salt  horse,"  and  pudding.  Recent  researches 
make  it  evident  that  pellagra  is  a  similar  "deprivation"  dis- 
ease, due  to  a  too-exclusive  diet  of  salted  meats  and  cereals, 
particularly  Indian  corn. 

Water,  Oxygen,  Etc.  Water  constitutes  between  80  and 
90  per  cent,  of  the  human  body,  and  a  liberal  supply  is  essen- 
tial for  the  greatest  efficiency  in  digestion  and  metabolism. 
It  is  to  be  remembered  that  the  body  is  not  entirely  depend- 
ent for  its  water-supply  on  fluids  ingested  as  such.  Most  of 
the  so-called  solid  foods  contain  a  liberal  percentage  of  water, 
often  as  much  as  70  per  cent.,*  while  during  the  course  of 
destructive  metabolism  considerable  additional  amounts  of 
water  ("chemical")  are  split  off  from  the  solid  constituents 
of  the  diet.  Water  is  eliminated  principally  through  the  kid- 
neys, skin,  lungs  and  intestines.  The  kidneys  and  skin,  with 
a  uniform  supply,  act  reciprocally,  to  a  large  extent,  in  accord- 
ance with  the  degree  of  external  heat.  Although  a  liberal 
supply  of  water  is  advisable,  the  body  shows  a  remarkable 
adaptability  in  this  respect,  and  eliminates  and  retains  water 
according  to  the  demands  of  the  metabolism.  In  cardiovas- 
cular and  renal  disease,  an  excess  of  fluid  may  be  positively 
injurious,  in  that  it  burdens  an  overtaxed  heart  or  exceeds  the 
excretory  power  of  the  kidney. 

Oxygen  is  absorbed  into  the  blood  through  the  lungs,  and 
CO2  is  eliminated,  in  turn,  through  the   same  organs.     The 


*  1,  white  bread  35.6  per  cent.;  2,  ribs  of  beef,  70.9  per  cent.;  3,  halibut 
steak,  74.4  per  cent.;  4,  asparagus  (cooked),  91.6  per  cent. 


GENERAL   CONSIDERATIONS.  457 

amount  of  CO2  eliminated  bears  a  definite  mathematic  rela- 
tion to  the  amount  of  O2  intake.  If  the  amount  of  ox}'-gen 
inspired  and  the  amount  of  carbon  dioxid  expired  are  esti- 
mated for  a  definite  period,  and  the  result  is  stated  as  a  frac- 
tion (  ^Q-  ),  we  obtain  what  is  known  as  the  respiratory 
quotient.  The  respiratory  quotient  varies  with  dififerent  food- 
stuffs, so  that  by  testing-  the  gaseous  interchange  an  expert 
observer  may  tell  what  form  of  food  has  been  ingested.  The 
respiratory  quotient  for  carbohydrates  is  1,  for  fat  and  protein 
0.7  and  0.8,  respectively. 

General  Metabolism,  General  metabolism  is  best  meas- 
ured in  heat  units  or  calories.  The  kilogram  calorie,  which 
is  the  caloric  unit  used  in  medicine,  is  that  quantity  of  heat 
which  is  necessary  to  raise  the  temperature  of  one  liter  of 
water  one  degree*  centigrade.  The  caloric  values  of  foodstuffs 
may  be  determined  directly  by  burning  them  in  the  presence 
of  oxygen  in  an  apparatus  known  as  a  bomb  calorimeter. 
Their  physiolog'ic  caloric  value  is  computed  from  the  theoretic 
value  by  making  due  allowances  for  lack  of  absorption,  and 
in  the  case  of  protein  for  incomplete  utilization.  As  stated 
previously,  protein  and  carbohydrate  each  yield  4  available 
calories  per  gram  (15  grs.),  while  hydrocarbons  yield  9 
calories  (dry  weight).  The  factors  of  Riibner,  though  more 
often  used,  are  less  convenient,  and  no  more  accurate.*  Al- 
cohol, which,  in  small  quantities  is  oxidized  in  the  body  with 
the  production  of  heat,  yields  7  calories  per  gram  (15  grs.). 
Alcohol  is  useful  to  supplement  the  dietary  in  diabetes,  and 
in  that  condition  has  a  protein-sparing  power  similar  to  that 
of  carbohydrates. 

The  caloric  demands  of  the  animal  or  human  body  may 
be  actually  determined  in  specially  devised  calorimeters.  The 
heat  production,  under  conditions  of  absolute  rest  and  star- 
vation, is  known  as  the  basal  heat  production.  In  man  this 
amounts  roughly  toi  1  calorie  per  kilogram  (2.2  lbs.)  per 
hour,  or  24  calories  per  kilogram  daily.  A  more  accurate 
method  is  to  state  the  daily  requirements  in  terms  of  square 
meters   of    radiating   skin    surface.      Stated    in    this    form    35 


*  These  are:    protein  and  carbohydrate,  4.1  calories;   fat,  9.3  calories, 
per  gram. 


458        DISEASES    OF   METABOLISM    AND    NUTRITION. 

calories  per  hour  would  be  required  for  each  square  meter  of 
surface."  If  sufficient  food  be  now  given  exactly  to  meet 
these  theoretic  requirements,  it  will  be  found  in  practice  to 
be  deficient,  since  the  digestion  and  metabolism  of  the  food 
in  itself  demands  a  certain  amount  of  energy,  roughly  10  per 
cent.  This  will  bring  the  total  daily  requirements  to  26.4 
calories  per  kilogram  per  day.  Calculating  for  a  man  of 
70  kilograms  (156  lbs.),  or  2  square  meters  of  superficial 
surface,  the  basal  heat  requirement  plus  the  specific  dynamic 
factor  would  amount  to  1850  calories.  During  the  waking 
hours,  even  while  in  bed,  a  certain  additional  amount  of 
energy  is  expended  in  external  movements,  and  still  more 
with  each  additional  degree  of  activity.  Sitting  in  a  chair, 
with  the  ordinary  accompanying  movements,  involves  a  sup- 
plemental consumption  of  20  calories  per  hour  for  an  individ- 
ual of  70  kilograms.  Walking  on  the  level  is  said  to 
require  in  addition  160  calories  per  hour.*  Ordinarily  it  is 
sufficient  to  remember  that  an  adult  at  rest  in  bed  requires 
approximately  30  calories  for  each  kilogram  of  body  weight 
per  day  (14  per  lb.)  ;  if  he  follows  a  sedentary  life,  or  one 
which  involves  only  moderate  exertion,  he  requires  35  to  40 
calories  (16  to  18  per  lb.)  ;  with  more  vigorous  exercise  50,  or 
in  very  arduous  occupations  even  as  much  as  60  calories  per 
kilogram  (24  to  28  per  lb.)  Babies  and  young  children 
require  quantities  of  food  which  are  seemingly  altogether  out 
of  proportion  to  the  demands  of  their  elders.  This  may  be 
explained,  in  part,  by  their  relatively  large  radiating  surface 
in  proportion  to  weight,  and  by  their  greater  physical  activ- 
ity. In  addition,  a  small  amount  is  accounted  for  by  the 
requirements  incident  to  growth.  An  infant  at  birth  requires 
as  much  as  100  calories  for  each  kilogram  of  body  weight 
per  day  (50  per  lb.)  ;  by  the  end  of  the  first  year  approxi- 
mately 80  calories  suffice ;  throughout  childhood  the  require- 
ments are  appreciably  higher  than  in  adult  life.  A  knowledge 
of  caloric  values  and  caloric  requirements  is  particularly  desir- 


*  (70 -f-  7)  X  8=   616  calories   (sleeping  hours). 
(70-1-7+20)  X  16=1552  calories    (waking  hours). 
Two  hours  walk  on  level  320  calories. 

2488  calories  (in  round  numbers  2500). 
(Taylor,  A. :    Digestion  and  Metabolism.) 


GENERAL   CONSIDERATIONS. 


459 


460        DISEASES    OF   METABOLISM    AND    NUTRITION. 

able  in  the  treatment  of  obesity,  malnutrition  from  any  cause 
and  diabetes.  It  is  also  useful  in  the  dietetic  treatment  of 
many  diseases  outside  of  the  group  with  which  this  section 
deals,  for  example,  ulcer  of  the  stomach  and  typhoid  fever. 
Most  of  the  dietetic  tables  found  in  current  textbooks  are 
derived  directly  or  indirectly  from  the  analyses  of  Atwater 
and  Brvant.8  The  fuel  values  in  their  tables  are  calculated 
per  pound,  a  method  which  is  convenient  for  wholesale  pur- 
chasing, but  not  for  dietetic  purposes.  Locke,  Fisher,  and 
others^  have  variously  modified  these  tables  for  practical 
purposes.  Locke  classifies  the  foods,  and  gives  the  caloric 
values  and  the  chemical  compositions  of  portions  such  as  are 
ordinarily  consumed.  Fisher  suggests  an  arbitrary  unit  of 
100  calories,  and  gives  the  weight  and  composition  of  various 
foods  which  would  furnish  this  amount  of  energy.  In  most 
cases  these  portions  are  not  far  from  those  usually  taken; 
moreover,  the  convenience  of  this  plan  is  not  materially  less- 
ened if  we  employ  in  some  cases  fractional  portions  instead 
of  whole  units.  The  appended  chart  is  based  on  this  principle 
(Table  II).  Another  convenient  plan  is  to  use  simple  units 
of  100  grams  each.  Taking  the  percentage  figures  for  pro- 
tein, fat  and  carbohydrate  as  given  by  Atwater  and  Bryant, 
one  can  readily  obtain  the  caloric  values  desired  by  multiply- 
ing the  figures  for  protein  and  carbohydrate  by  4,  and  those 
for  fat  by  9,  and  adding  the  results  together. 

Table  III  has  been  calculated  on  this  plan.  In  many 
instances  simple  fractions  or  multiples  of  100  grams  may 
be  employed ;  100  grams  correspond  roughly  to  3^4  ounces 
avoirdupois,  or,  in  the  case  of  liquids,  to  a  little  over  3  fluid- 
ounces  (Apothecaries'  measure). 

Table   III. 

Soups.  P.  F.  C-H.  Gal.* 

Bean-soup    3.2  1.4  9.4  63.0 

Beef-juice    4.9  0.6  25.0 

Beef-soup    4.4  0.4  1.1  25.6 

Bouillon     2.2  0.1  0.2  10.5 

Chicken-soup    3.6  0.1  1.5  21.3 

Clam    chowder    1.8  0.8  6.7  41.2 

Consomme    2.5  0.4  11.6 

Cream   of   asparagus    2.5  3.2  5.5  60.8 

*  P.  =  protein;   F.  =  fat;   C-H.  =  carbohydrate;   Cal.  =  calories. 


F. 

C-H. 

Cal. 

2.8 

5.0 

53.6 

0.9 

2.8 

40.1 

0.7 

7.6 

51.1 

0.9 

5.3 

36.1 

GENERAL   CONSIDERATIONS.  461 

Table  III — Continued. 

Soups — continued.  p. 

Cream  of  celery    2.1 

Mock-turtle    soup    5.2 

Pea-soup    3.6 

Tomato-soup    1.7 

Meats. 

Porterhouse    steak    21.9        20.4                        271.2 

Ribs  of  beef 

Lean    19.6 

Fat    15.0 

Round  of  beef 

Lean    21.3 

Fat    17.5 

Sirloin    steak 18.9 

Tenderloin    broiled    19.8 

Veal  cutlet   20.3 

Veal  loin 

Medium    fat    19.9 

Lamb-chops,    broiled    21.7 

Lamb,  leg    (roast)    19.7 

Mutton,  leg   19.8 

Pork,  loin  chops 

Medium    fat    16.6 

Pork-ribs    17.3 

Ham,   lean    25.0 

Chicken — broilers    21.5 

Fowl     19.3 

Goose    16.3 

Turkey,    roast     27.8 

Fisli. 

Clams,  round   6.5 

Cod,   fresh    11.1 

Crabs,    hard-shell     16.6 

Haddock    17.2 

Halibut   steak    18.6 

Lobster    16.4 

Mackerel,    fresh    18.7 

Oysters,  raw    6.2 

Sahnon,   canned    21.8 

Sardines,   canned    23.0 

Sea-bass    19.8 

Eggs. 

Hen's  eggst 

Uncooked    14.8 

Boiled    14.0 

Vegetables. 

Asparagus    cooked     2.1 

Beans    baked — canned     6.9 

Beans,  lima    7.1 

Beans,    lima — canned    4.0 

Beans,   red   kidney — canned    7.0 

Beans,   string — cooked    0.8 


12.0 

186.4 

35.6 

380.4 

7.9 

156.3 

16.1 

214.9 

18.5 

242.1 

11.8 

185.4 

7.7 

150.5 

10.8 

176.8 

29.9 

355.9 

12.7 

193.1 

12.4 

190.8 

30.1 

337.3 

13.1 

187.1 

14.4 

229.6 

2.5 

108.5 

16.3 

223.9 

36.2 

391.0 

18.4 

276.8 

0.4 

29.6 

0.2 

46.2 

2.0 

84.4 

0.3 

71.5 

5.2 

121.2 

1.8 

81.8 

7.1 

138.7 

1.2 

35.6 

12.1 

196.1 

19.7 

269.3 

0.5 

83.7 

10.5 

153.7 

12.0 

164.0 

3.3 

2.2 

46.9 

2.5 

19.6 

128.5 

0.7 

22.0 

122.7 

0.3 

14.6 

77.1 

0.2 

18.5 

103.8 

1.1 

1.9 

20.7 

t  Two  eggs  weigh  approximately  100  grains. 


462       DISEASES    OF   METABOLISM    AND    NUTRITION. 

Table  III — Continued. 
Vegetables — continued.  p. 

Beets,   cooked    2.3 

Cabbage     1.6 

Carrots    1.1 

Cauliflower    2.0 

Celery    1.1 

Corn,    green    3.1 

Corn,   green — canned    2.8 

Cucumbers    0.8 

Olives     1.1 

Onions,  cooked  1.2 

#      Parsnips    1.6 

Peas,    dried    24.6 

Peas,  green — cooked   6.7 

Potatoes,  boiled    2.5 

Potato  chips    6.8 

Potatoes,  mashed  and  creamed    . . .  2.6 

Spinach,  cooked   2.1 

Sweet   potatoes,    cooked    3.0 

Tomatoes,   canned    1.2 

Tomatoes,    fresh    0.9 

Breads  and  Cereals. 

Bread,   home-made    9.1 

Bread,   rye    9.0 

Bread,   toasted    11.5 

Bread,   white — baker's    10.6 

Crackers,   Boston    11.0 

Crackers,   graham    10.0 

Crackers,   soda    9.8 

Hominy,  cooked   2.2 

Macaroni,   cooked    3.0 

Oatmeal,   boiled    2.8 

Rice,  boiled    2.8 

Rolls,   French    8.5 

Shredded   wheat    10.5 

Dairy  Products. 

Butter 1.0 

Cheese,   American   pale    28.8 

Cheese,   cottage  (no  cream  added)     .  20.9 

Cheese,   full  cream    25.9 

Cheese,  Neufchatel    18.7 

Cream    2.5 

Evaporated  cream    9.6 

Skimmed   milk    3.4 

Fruits  and  Desserts. 

Apples    0.4 

Bananas     1.3 

Dates 2.1 

Figs,  dried 4.3 

Grapes    1.0 

Oranges    0.8 

Orange  marmalade    0.6 

Peaches    0.7 

Raisins    2.6 

Strawberries    1.0 


F. 

C-H. 

Cal. 

0.1 

7.4 

39.7 

0.3 

5.6 

31.5 

0.4 

9.3 

45.2 

0.8 

6.0 

39.2 

0.1 

3.3 

18.5 

1.1 

19.7 

101.1 

1.2 

19.0 

98.0 

0.2 

3.1 

17.4 

27.6 

11.6 

299.2 

1.8 

4.9 

40.6 

0.5 

13.5 

64.9 

1.0 

62.0 

355.4 

3.4 

14.6 

115.8 

0.1 

20.9 

94.5 

39.8 

46.7 

572.2 

3.0 

17.8 

108.6 

4.1 

2.6 

55.7 

2.1 

42.1 

199.3 

0.2 

4.0 

22.6 

0.4 

3.9 

22.8 

1.6 

53.3 

264.0 

0.6 

53.2 

254.2 

1.6 

61.2 

305.2 

1.2 

48.3 

246.4 

8.5 

71.1 

404.9 

9.4 

73.8 

419.8 

9.1 

73.1 

413.5 

0.2 

17.8 

81.8 

1.5 

15.8 

88.7 

0.5 

11.5 

61.7 

0.1 

24.4 

109.7 

2.5 

55.7 

279.3 

1.4 

77.9 

366.2 

85.0 

769.0 

35.9 

438.3 

1.0 

92.6 

33.7 

406.9 

27.4 

321.4 

18.5 

176.5 

9.3 

122.1 

0.3 

16.3 

0.5 

14.2 

62.9 

0.6 

22.0 

98.6 

2.8 

78.4 

347.2 

0.3 

74.2 

316.7 

1.2 

14.4 

72.4 

0.2 

11.6 

51.4 

0.1 

84.5 

341.3 

0.1 

9.4 

41.3 

3.3 

76.1 

344.5 

1.6 

7.4 

48.0 

SCURVY    (SCORBUTUS).  453 


Table  III — Continued. 

Fruits  and  Desserts — continued.  p.            f. 

Almonds     11.5        30.2 

Chestnuts    6.2          5.4 

Peanuts    25.8        38.6 

Pecans    9.6        70.5 

Calf's  foot  jelly  4.3 

Cup   cake    5.9          9.0 

Sponge   cake    6.3         10.7 

Pie,    apple 3.1          9.8 

Pudding,  tapioca    Z.Z          3.2 

Granulated    sugar    

Honey    0.4 

Maple   syrup    


SCURVY  (Scorbutus) 
SCURVY    IN    ADULTS.io 


C-H. 

Cal. 

9.5 

355.8 

42.1 

241.8 

24.4 

548.2 

15.3 

734.1 

17.4 

86.8 

68.5 

378.6 

65.9 

385.1 

42.8 

271.8 

28.2 

154.8 

100.0 

400.0 

81.2 

326.4 

71.4 

285.6 

Scurvy  is  a  disease  which  is  almost  unknown  in  private 
practice,  although  well-marked  cases  are  not  at  all  uncom- 
mon in  public  institutions,  and  may  be  readily  diagnosed  if 
one  bears  the  disease  in  mind.  There  have  been  many  examples 
at  the  Philadelphia  General  Hospital,  from  which  institution 
cases  have  been  reported  by  Henry,  Riesman,  Jump  and 
others. 11  Formerly  a  scourge  of  the  sea,  it  is  now  more 
common  on  land.  Aside  from  its  sporadic  occurrence,  it 
appears  in  epidemic  form  in  times  of  war,  famine  and  pesti- 
lence. The  "terrible  malady  of  hunger"  in  Poland,  recently 
(1916)  described  in  the  public  prints,  appears  to  have  been 
scurvy,  or  something  closely  allied  to  it. 

In  the  prodromal  stag-es  scurvy  is  characterized  by  mental 
apathy  and  depression,  by  extreme  lassitude  and  muscular 
weakness,  and  by  pallor,  dyspnea  and  slight  edema.  In  its 
fully  developed  form  the  foregoing  symptoms  are  present, 
and,  in  addition,  the  gums  are  red  and  swollen,  the  lower 
extremities  are  dotted  with  petechije,  and  occasionally  with 
larger  hemorrhagic  spots,  and  the  subcutaneous  tissues,  in 
certain  localities,  are  discolored  by  ecchymoses.  There  may 
also  be  subperiosteal  hemorrhages.  In  the  later  stages  there 
may  be  increasing  anemia,  cardiac  weakness,  dyspnea  and 
edema,  and  death  may  occur  from  syncope.  The  usual  com- 
plications are  ulceration  of  the  skin  and  of  the  mucous  mem- 
branes, hemorrhagic  effusion  into  the  pleural,  pericardial  or 


464       DISEASES    OF   METABOLISM    AND    NUTRITION. 

joint  cavities,  pulmonary  gangrene,  and  bloody  diarrhea.* 
The  severer  types  of  the  disease  are  now  excessively  rare, 
dangerous  complications  are  uncommon,  and  a  fatal  outcome 
is  most  unusual.  Many  theories  have  been  advanced  to 
account  for  the  disease,  notably  that  of  Garrod  (1848)12  who 
attributed  it  to  a  lack  of  potassium  salts;  of  Wright,!^  ^ho 
considered  it  a  manifestation  of  acid  intoxication,  and  of 
Torup,!^  who  incriminated  ptomaine  poisoning  (from  badly 
preserved  or  tainted  meat  and  fish).  Other  writers^^  have 
thought  it  to  be  due  to  a  specific  infection  seated  in  the  gums 
or  elsewhere.  At  present  the  trend  of  opinion  is  to  group 
scurvy  with  the  "deficiency  diseases,"  such  as  beriberi,  scurvy, 
pellagra  and  rickets.  Casimir  Funk^^  has  designated  this 
group  by  the  general  name  of  "Avitaminosen."  He  and 
others  have  attempted  to  isolate,  by  chemical  means  and  ani- 
mal experimentation,  vitamins  similar  to  those  found  curative 
in  beriberi,  but  as  yet  this  attempt  has  not  been  successful. 
Nevertheless,  the  vitamin  theory  seems  to  be  the  most  rea- 
sonable of  any  yet  advanced.  Practically  speaking,  the  etiol- 
ogy of  scurvy  is  well  known.  It  is  brought  about  by  a 
monotonous  diet,,  consisting  largely  of  salted  or  otherwise 
preserved  meats  and  cereal  foods,  and  deficient  or  entirely 
lacking  in  fresh  fruits,  green  vegetables  and  tubers.  A  patient 
who  was  treated  at  the  Philadelphia  Hospital  (service  of  Dr. 
Riesman)  had  subsisted  on  a  diet  consisting  solely  of  sausage, 
bread  and  doughnuts.  Canned  fruits  and  vegetables  may,  or 
may  not,  possess  antiscorbutic  properties.  These  properties 
seem  to  be  better  preserved  in  the  presence  of  organic  acids, 
as  in  lime-juice,  lemons,  oranges  and  sauerkraut.  Other  con- 
tributory causes  are  bad  air,  filthy  surroundings,  insufficient 
clothing,  exposure  to  wet  and  cold,  hard  work,  and  chronic 
diseases.  All  these  conditions  were  to  be  found  in  the  fore- 
castles of  the  old-time  sailing-ships ;  with  the  introduction  of 
steam,  voyages  became  short,  and  fresh  food  always  available. 
Steam  is  thus  given  almost  equal  credit  with  lime-juice  as  a 
factor  in  the  abolition  of  sea-scurvy. 


*  In  the  polar  regions  "night  bHndness"  is  a  common  complication.  The 
intense  light  of  the  arctic  day  exhausts  the  retina;  scurvy  is  merely  a  pre- 
disposing cause. 


SCURVY    (SCORBUTUS).  465 

There  are  very  few  pathologic  changes  typical  of  scurvy 
in  adults.  If  incisions  are  made  into  the  ecchymotic  swell- 
ings in  the  neighborhood  of  the  ankle,  in  the  popliteal  space 
and  elsewhere,  the  subcutaneous  tissues  and  muscles  will  be 
found  to  be  infiltrated  with  bloody  serum,  or  there  may  be 
dense  clots  of  blood.  The  serous  cavities  may  contain  blood- 
stained effusions.  The  heart-muscle  is  usually  soft  and  degen- 
erated, and  the  spleen  congested  and  softened.  The  blood- 
vessels have  always  been  found  normal.  Complicated  cases 
may  show  dysenteric  ulceration  and  gangrene  of  the  lungs. 

The  onset  of  the  disease  is  gradual,  and  the  patient  may 
come  to  the  hospital  on  account  of  extreme  lassitude  and 
inability  to  work.  He  is  usually  pallid  ("earthy  pallor"),  and 
may  be  somewhat  dyspneic.  By  the  time  he  comes  under 
observation  the  gums  are  swollen  and  of  a  deep-red  color,  but 
if  the  teeth  are  lacking  this  symptom  may  be  absent.  The 
skin  is  rough  and  dry,  and  minute  hemorrhagic  points  are 
scattered  profusely  over  the  lower  extremities.  There  may 
also  be  tender  nodes  along  the  tibia.  In  the  neighborhood 
of  the  ankle,  at  the  back  of  the  knee,  and  in  the  thigh  the 
loose  subcutaneous  tissues  may  be  infiltrated,  producing  a 
superficial  appearance  of  severe  trauma :  heat,  redness,  swell- 
ing and  ecchymosis.  These  lesions  of  the  gums,  skin  and  sub- 
cutaneous tissues  are  considered  by  some  authorities  to  be 
accidental  complications^'''  rather  than  essential  symptoms  of 
the  disease.  However,  even  if  they  are  directly  due  to  fric- 
tion or  slight  trauma,  they  are  indirectly  referable  to  the  state 
of  the  blood.  Scurvy  as  we  now  see  it  is  a  benign  disease 
with  practically  no  mortality.  The  patients  may  appear  the 
picture  of  misery,  but  a  suitable  diet  will  restore  them  to 
normal  health  within  a  few  weeks  at  the  most.  The  severer 
types  of  the  disease  are  now  almost  unknown,  but  it  would 
not  be  surprising  if  they  should  reappear  in  certain  regions 
before  the  present  European  war  is  ended. 

TREATMENT. 

The  prophylactic  treatment  of  scurvy  has  for  generations 
been  prescribed  by  law  in  the  navy  and  mercantile  marine  of 
almost  all  nations.  The  use  of  lime-juice  was  first  introduced 
in  the  British  navy,  so  that  vessels  of  that  nation  were  satiric- 

30 


466       DISEx\SES    OF   METABOLISM    AND    NUTRITION. 

ally  described  as  "lime-juicers."  The  dietaries  of  hospitals, 
asylums,  prisons  and  convict  camps  have,  however,  not  always 
been  above  reproach ;  so  that  "deficiency  diseases" — whether 
scurvy,  pejlagra  or  beriberi — have  cropped  out  from  time  to 
time.  Vedder^s  in  a  recent  article  has  formulated  some  sim- 
ple dietary  rules  which  will  suffice  for  the  prevention  of 
deficiency  diseases: 

1.  "In  any  institution  where  bread  is  the  staple  article  of 
diet,  it  should  be  made  from  whole-wheat  flour. 

2.  "When  rice  is  used  in  any  quantity,  the  brown  under- 
milled,  or  so-called  hygienic  rice,  should  be  furnished. 

3.  "Beans,  peas  or  other  legumes,  known  to  prevent  beri- 
beri, should  be  served  at  least  once  a  week.  Canned  beans  or 
peas  should  not  be  used. 

4.  "Some  fresh  vegetable  or  fruit  should  be  issued  at  least 
once  a  week,  and  preferably  at  least  twice  a  week. 

5.  "Barley,  a  known  preventive  of  beriberi,  should  be  used 
in  all  soups. 

6.  "If  cornmeal  is  the  staple  of  diet,  it  should  be  yellow 
meal  or  water-ground  meal,  that  is,  made  from  the  whole 
grain. 

7.  "White  potatoes  and  fresh  meat,  known  preventives  of 
beriberi  and  scurvy,  should  be  served  at  least  once  a  week,  and 
preferably  once  daily. 

8.-  "The  too  exclusive  use  of  canned  goods  must  be  care- 
fully avoided." 

DIETARY. 

In  the  treatment  of  a  developed  case  of  scurvy  the  diet  will 
be  the  determining  factor.  This  should  include  primarily 
orange-juice  or  lemonade,  fruits,  green  vegetables — such  as 
lettuce,  cabbage  and  spinach — and  potatoes.  Secondarily,  it 
should  include  an  adequate  supply  of  nourishing  food,  milk, 
eggs,  fresh  meat  and  bread,  preferably  whole-wheat  bread. 
All  these  articles  are  more  or  less  antiscorbutic,  though  less 
so  than  the  fruit  juices  and  the  vegetables  first  mentioned. 
Fresh  meat,  containing  the  tissue  juice  and  blood,  is  a  good 
preventive,  but  preserved  meats  in  which  the  animal  juices 
have  been  replaced  by  preserving  fluids  are  eminently  con- 
ducive to  this  disease. 1^     In  the  same  way  boiling  and  pas- 


SCURVY    (SCORBUTUS).  ^67 

teurization  detract  from  the  antiscorbutic  value  of  milk. 
Some,  but  not  all,  vegetables  and  fruits  preserve  their  anti- 
scorbutic virtue  when  canned  or  dried.  This  is  particularly 
true  of  lime-juice,  and  various  preparations  of  cabbage. 

HYGIENE. 

Faulty  hygiene  and  unfavorable  climatic  conditions  have 
played  a  large  part  in  the  history  of  scurvy.  Like  typhus 
fever,  it  is  a  disease  which  is  associated  in  our  minds  with 
misery  and  squalor.  It  will  be  greatly  ameliorated  by  good 
ventilation,  light,  cleanliness, — in  fact,  all  those  conditions 
which  characterize  a  well-conducted  hospital.  It  is  quite 
unnecessary  to  specify  these  obvious  matters  in  detail. 

DRUGS. 

At  the  first  visit  the  patient  will  require  a  laxative,  as  the 
bowels  are  usually  constipated,  for  which  purpose  Rochelle 
salts  are  best  suited,  as  they  act  both  as  a  laxative  and  antacid. 
Wright  recommended  that  this  drug  be  repeated  several  times 
a  day,  with  a  view  of  overcoming  the  acidosis  which  he  pos- 
tulated. He  also  recommended  calcium  chlorid  to  increase 
the  coagulability  of  the  blood.  At  the  present  day  calcium 
lactate  is  to  be  preferred  to  the  chlorid,  15  grains  (1  Gm.) 
four  times  a  day  being  a  suitable  dose. 

For  the  loss  of  appetite  any  of  the  ordinary  bitters  may 
be  prescri1:)ed.  The  secondary  anemia  would  suggest  the  use 
of  iron  in  some  eligible  form, — for  example,  as  Blaud's  mass. 
If  there  be  a  tendency  to  hemorrhage  from  the  mucous  mem- 
branes, an  astringent  preparation  of  iron  would  be  preferable, 
such  as  the  tincture  of  the  chlorid. 

The  mouth  should  be  carefully  cleansed  with  potassium 
permanganate  solution  (0.1  per  cent.),  or  a  mild  antiseptic 
solution  such  as  liquor  antisepticus  (N.  F.),  and  the  gums 
touched  with  iodin.  In  case  ulceration  occurs,  nitrate  of  sil- 
xer  (10  per  cent.)  may  be  applied  locally.  Emetin  has  been 
used  without  very  definite  results.  Although  all  the  sugges- 
tions which  have  been  made  have  a  rational  basis,  they  are 
quite  secondary  to  the  diet,  which,  in  the  writer's  experience,  is 
in  itself  quite  sufficient  to  effect  a  speedy  cure  in  the  ordinary 
case. 


468       DISEASES    OF   METABOLISM    AND    NUTRITION. 

"Ship  beriberi,"  which,  according-  to  Funk-*^  was  exhaus- 
tively investig-ated  by  Nocht  in  1903,  is  closely  related  to 
scurvy  in  its  etiology  and  symptoms.  Funk  says  that  the 
characteristic  symptoms  are  anesthesia  in  the  extremities, 
shortness  of  breath,  and  finally  death  from  heart-weakness. 
In  contrast  to  tropic  beriberi,  patients  recover  very  quickly 
when  they  receive  fresh  provender. 

INFANTILE    SCURVY.* 
(Barlow's    Disease;    Acute  Rickets.) 

Infantile  scurvy  is  a  constitutional  disease  due  to  unsuit- 
able food,  given  for  a  prolonged  period  of  time.  It  is  an 
entirely  preventable  nutritional  disorder.  Although  occa- 
sionally it  develops  among  breast-fed  infants,  it  is  essentially 
a  disease  of  the  bottle-fed,  and  is  common  among  those  babies 
who  are  fed  for  some  time  upon  proprietary  food,  condensed 
milk,  sterilized,  and  boiled  or  pasteurized  milk.  Even  butter- 
milk, prepared  by  heating,  is  a  potential  cause  of  infantile 
scurvy.  Very  rarely,  a  greatly  diluted  raw  milk  may  produce 
scurvy,  if  the  baby  be  kept  upon  it  for  a  long  time. 

There  must  exist  an  "individual"  predisposition  to  infan- 
tile scurvy, -1  since  only  a  small  proportion  of  improperly  fed 
infants  develop  this  disease. 

Holt  and  Rowland-^  note  that  only  one  of  twins  fed  in 
exactly  the  same  way  developed  scurvy.  The  so-called  "exu- 
dative diathesis"  of  Czerny  belongs  definitely  among  the  pre- 
disposing causes  of  infantile  scurvy,  which  is  the  same  disease 
as  ordinary  scurvy,  but  modified  by  the  different  conditions 
incident  to  infancy.  Some  chemical  change,  with  destruction 
of  the  "vitamins,"  occurs  in  food  prepared  by  overheating, 
which  makes  such  food  less  assimilable.  Infants  fed  exclu- 
sively upon  such  food  show  disturbances  of  metabolism,  and 
infantile  scurvy  develops  very  gradually. 

Infantile  scurvy  is  associated  with  symptoms  of  rickets  in 
about  one-half  of  all  cases,  but  there  is  no  relation  between 
the  presence  of  the  rickets  and  the  development  of  the  scurvy. 
While  rickets  results  from  an  inability  properly  to  digest 
improper   food,    which    contains   a    deficiency    of   fat    and    an 


*  By  Maurice  Ostheimer,  M.D.,  Associate  in  Pediatrics,  University  of 
Pennsylvania. 


INFANTILE    SCURVY.  469 

excess  of  carbohydrates,  infantile  scurvy  is  the  direct  result 
of  unsuitable  food,  which  is  usually  well  digested. 

Though  scurvy  has  been  noted  in  infants  less  than  1  month 
old,  it  is  most  frequently  found  in  babies  of  between  6  and  15 
months  of  age,  who  have  been  well  previously.  While  rickets 
is  a  disease  of  the  poor,  scurvy  more  frequently  occurs  among 
the  well-to-do.  Surroundings  play  no  role  in  the  development 
of  infantile  scurvy,  nor  is  there  any  history  of  previous  illness ; 
not  even  of  frequent  digestive  disturbances. 

There  is  undoubtedly  an  intimate  causal  association 
between  scurvy,  rickets  and  beriberi,  since  all  three  are 
primarily  the  result  of  improperly  handled  or  prepared  food- 
stuffs, in  which  the  "vitamins"  are  either  lacking  or  have  been 
destroyed.  The  constituents  of  these  foods  have  been  so 
altered  that  the  proper  balance  of  the  mineral  salts  within  the 
organism  is  upset.  While  there  is  a  definite  loss  of  calcium 
in  rickets,  there  is  in  scurvy  an  unexplained  calcium  retention. 

Infantile  scurvy,  as  described  originally  by  Sir  Thomas 
Barlow,-^  is  characterized  by  (1)  immobility,  a  pseudopa- 
ralysis, of  the  lower  limbs  especially,  accompanied  by  exces- 
sive tenderness  and  by  swelling,  due  mainly  to  subperiosteal 
hemorrhage,  to  edema  with  skin  tense  and  shiny,  and  to 
thickening  of  the  long  bones,  which  is  noted  only  after  the 
swelling  has  disappeared ;  (2)  swelling  of  the  gums,  generally 
with  ecchymosis;  (3)  a  tendency  to  hemorrhage;  and  (4) 
prompt  recovery  upon  antiscorbutic  diet.  These  symptoms 
develop  gradually,  with  prolonged  malnutrition,  marked 
pallor,  anemia  and  emaciation.  The  bab}^  cries  not  only 
when  handled,  but  even  when  approached ;  the  gums  become 
red  and  swollen,  and  bleed  easily.  If  untreated,  the  tender- 
ness spreads  to  practically  all  bones,  with  ecchymoses  and 
hemorrhages  in  various  parts  of  the  body,  Hess--*  noted 
enlargement  of  the  right  ventricle  (as  in  beriberi),  and  a 
diminution  of  the  clotting  power  of  the  blood. -"^  Petechial 
hemorrhages  into  the  skin  and  mucous  membranes  have  been 
noted  very  earh^  in  the  disease. 

When  not  treated  infantile  scurvy  is  invariably  fatal ; 
moreover,  these  infants  are  most  susceptible  to  any  intercur- 
rent infection,  which  may  rapidly  prove  fatal. 


470       DISEASES    OF   METABOLISM    AND    NUTRITION. 

Subperiosteal  hemorrhages  are  constantly  found  near  the 
epiphyseal  junction,  sometimes  with  separation  of  the  epi- 
ph3^sis.  This  hemorrhage  may  extend  into  the  muscles, 
though  rarely  into  the  joint.  These  hemorrhages  are  prob- 
ably due  to  an  existing  hemorrhagic  diathesis.  They  extend 
into  the  subcutaneous  tissue,  with  exophthalmos  in  the  orbit, 
or  causing  hematoma  in  the  cheek  or  eyelid ;  into  the  gums, 
mucous  or  serous  membranes,  and  even  into  the  dura,  kid- 
ney and  spleen. 

Microscopically,  a  rarefying  process  is  noted  in  the  long 
bones,  with  hemorrhages  in  the  marrow  and  under  the  peri- 
osteum. The  number  of  osteoblasts  is  decreased,  and  new 
bone  is  not  formed.  Bone  already  formed  is  well  calcified,  and 
absorption  of  bone  is  not  increased. 

In  skiagrams  a  definite  "line"  is  found  at  the  junction  of 
diaphysis  and  epiphysis  in  the  long  bones.  This  is  noticed 
very  early  in  infantile  scurvy,  even  before  cardinal  symptoms 
appear.  It  persists  for  months,  even  after  the  infant  appar- 
ently has  recovered  clinically.  It  is  of  value,  especially  in  the 
diagnosis  of  the  severe  type  of  scurvy,  with  high  fever  and 
leucocytosis,  to  exclude  acute  pyogenic  infection. 

Infantile  scurvy  ought  never  to  be  mistaken  for  any  other 
condition,  since  history  and  clinical  findings  are  usually 
typical.  Rheumatism  does  not  occur  in  infancy;  anterior 
poliomyelitis  is  readily  distinguished  by  loss  of  the  reflexes 
and  examination  of  the  cerebrospinal  fluid.  The  skiagram 
also  confirms  the  diagnosis.  Traumatism,  joint  disease,  spinal 
caries,  and  malignant  bone  disease  may  occasionally  some- 
what resemble  scurvy. 

While  the  undernourished  infant  may  continue  to  increase 
in  weight  during  the  development  of  infantile  scurvy,  most 
babies  fail  to  grow,  either  in  weight  or  in  length,  but  remain 
stationary  during  the  development  of  scurvy.  In  infantile 
atrophy,  on  the  contrary,  growth  in  length  is  not  afifected,  the 
infant  failing  to  gain  in  weight  alone. 

TREATMENT. 

It  is  very  rare  for  a  breast-fed  baby  to  develop  infantile 
scurvy ;  when  this  occurs,  examination  of  the  mother's  milk 
will  show  its  abnormal  composition.     Next  to  breast  milk  in 


RICKETS    (RACHITIS).  4/1 

excellency  comes  raw  cows'  milk  (certified  milk),  not  steri- 
lized or  pasteurized.  As  certified  milk  is  expensive,  many 
babies  must  take  pasteurized  milk ;  in  such  instances  orange- 
juice  should  also  be  given  as  a  prophylactic,  without  regard 
to  the  age  of  the  baby.  If  for  any  reason  condensed  milk  or 
any  proprietary  food  should  be  chosen,  temporarily,  clean  raw 
milk  should  be  used  with  it,  and  orange-juice  given  regularly 
also. 

When  the  disease  has  already  developed,  all  unsuitable 
food  should  be  stopped  at  once.  Here,  again,  raw  cows'  milk 
should  be  given.  Spring-water  is  always  advisable  for  these 
infants,  yz  to  1  ounce  (15  to  30  mils),  warmed,  about  one 
hour  before  each  feeding.  Infants  over  1  year  old  may  also 
be  fed  any  cereal  containing  the  outer  layers  of  the  grain. 

Because  of  the  extreme  tenderness,  the  infant  should  be 
kept  at  rest,  undisturbed  for  several  days,  until  the  effect  of 
the  orange-juice  is  noted.  In  any  severe  case  the  affected 
limb  may  be  kept  in  a  splint  for  some  days. 

Orange-juice,  the  specific  treatment  for  infantile  scurvy, 
is  given,  }4  to  1  ounce  (15  to  30  mils),  every  two  or  three 
hours,  alone  or  diluted  with  spring-water.  The  juice  of  a 
whole  orange  should  be  given  daily.  Orange-peel  may  also  be 
squeezed  and  added  to  the  orange-juice.  Lemon-juice  is  not 
so  good,  because  it  must  be  sweetened  as  well  as  diluted. 
Fresh  grape-juice  is  of  value  when  available. 

For  children  over  1  year  of  age  a  mashed-potato  gruel  may 
also  be  given.  Fresh  green  vegetables,  such  as  spinach,  well 
cooked,  are  also  of  value. 

On  account  of  the  secondary  anemia,  syrup  of  the  iodid 
of  iron,  5  to  15  drops  (0.30  to  0.92  mils),  may  be  given  three 
or  four  times  a  day.  Beef-juice  and  codliver  oil,  so  frequently 
forced  upon  infants  with  scurvy,  are  of  no  value  at  all,  either 
in  the  prophylaxis  or  in  the  treatment  of  infantile  scurvy. 

RICKETS    (Rachitis).* 
Rickets  is  a  chronic  nutritional  disorder  of  infants,  char- 
acterized especially  by  the  abnormal  development  of  bone  and 
cartilage,  with   subsequent  deformity ;  the  aft'ection  is  trace- 


*  By  Maurice  Ostheimer,  M.D.,  Associate  in  Pediatrics,  University  of 
Pennsylvania, 


472       DISEASES    OF   METABOLISM    AND    NUTRITION. 

able  directly  to  the  prolong-ed  feeding  of  indigestible  food, 
and  to  faulty  hygiene.  Digestive  disturbances  constantly  pre- 
cede the  development  of  rickets,  w^hich  is  attended  by  disturb- 
ances of  metabolism  and  a  definite  loss  of  calcium  salts. 

Rickets  has  at  least  two  definite  causes,,  improper  food  and 
defective  hygiene,  especially  lack  of  fresh  air  w^ith  defective 
air-space,  due  to  confinement  indoors.  Therefore,  it  most 
commonly  develops  in  winter.  It  usually  affects  infants  6  to 
18  months  old,  and  is  slightly  more  frequent  in  boys  than  in 
girls.  These  babies  are  either  bottle-fed  or  receive  table  food; 
in  either  case,  improper  food  for  the  individual  infant. 

The  importance  of  overfeeding  in  the  causation  of  rickets 
has  been  discussed  by  Esser,^^  and  recently  by  Eric  Prit- 
chard,-"  who  believes  that  rickets  invariably  results  from  a 
relative  excess  of  food,  with  the  production  of  an  acidosis. 
As  the  organism  attempts  to  overcome  this  by  compensatory 
overactivity  of  the  hematogenetic  centers  in  the  long  bones, 
the  deformities  of  rickets  develop. 

The  food  given  most  of  the  infants  who  develop  rickets 
has  been  found  to  contain  little  fat  and  a  great  excess  of 
carbohydrates.  The  proprietary  food,  therefore,  plays  an 
important  etiologic  role.  When  rickets  occurs  among  breast- 
fed babies,  it  will  be  found  that  either  the  mother  is  decidedly 
undernourished  or  has  been  nursing  her  baby  over  too  long 
a  period,  or  that  the  infant  has  also  had  table  food.  Rarely 
a  child  whose  mother  has  previously  nursed  more  than  three 
children  over  a  protracted  period  develops  rickets,  due  to 
what  Fordyce  calls  "previous  lactational  strain."28 

Thus  it  follows  that  rickets  is  almost  universal  among  the 
poor,  especially  in  the  large  cities.  While  rare  in  the  country, 
it  also  occurs  there  when  an  infant  is  improperly  fed.  It  is 
most  common  among  negroes  in  the  United  States,  who  get 
table  food  practically  from  birth,  though  they  may  also  be 
breast-fed  for  two  years  or  longer.  It  also  occurs  frequently 
in  the  breast-fed  babies  of  foreign-born  mothers  whose  breast 
milk  shows  the  results  of  the  mothers'  malnutrition. 

Although  both  parents  and  grandparents  may  have  had 
rickets  in  infancy,  this  is  readily  explained  by  the  fact  that 
both  the  child's  mother  and  grandmother  may  have  been  so 
undernourished    that   the    milk    secreted   was    also    at   fault. 


RICKETS    (RACHITIS).  473 

Heredity,  however,  may  exert  some  influence  similar  to  that 
of  those  chronic  diseases  upon  which  Marfan-'^  places  such 
stress.  He  considers  that  rickets  is  always  due  to  some 
chronic  irritative  process  (alimentary,  infectious,  tuberculous 
or  syphilitic).  Syphilis  is  known  to  exist  in  many  children 
who  develop  rickets,  and  very  frequently  alimentary  disorders 
are  present. 

The  normal  growth  of  the  bones  is  altered.  The  carti- 
laginous layer  uniting  the  shaft  and  epiphysis  is  greatly 
widened  and  thickened.  The  transitional  zone  is  softer  than 
normal  cartilage,  blending  with  the  epiphyseal  cartilage  on 
one  side,  but  showing  an  irregular  dentate  border  on  the 
other.  Fibrous  tissue  replaces  normal  red  bone-marrow  near 
the  epiphysis.  A  softer  and  more  vascular  bone  results, 
unnaturally  flexible,  readily  producing  deformities  and  frac- 
tures. Calcium  is  excreted  in  excess,  so  that  the  occur- 
rence of  much  "limeless"  bone  is  the  most  striking  feature  in 
rickets. 

Definitely  constant  changes  are  noted  in  skiagrams :  de- 
layed ossification  and  indistinct  epiphyses;  fraying  out  of  the 
end  of  the  shaft  next  the  epiphyseal  line ;  broadening  of  the 
end  of  the  shaft  next  to  the  epiphysis;  cortical  thickening  on 
the  concave  side  of  the  curved  bones ;  and  areas  of  diminished 
density  in  the  bone  shadow  of  the  shaft.  In  the  acute  stage, 
besides,  periosteal  thickening  and  multiple  fractures  may  be 
observed. 

The  development  of  rickets  is  gradual,  and  is  always  pre- 
ceded by  several  attacks  of  digestive  disturbances.  Excessive 
perspiration  about  the  head,  restlessness,  constipation,  fre- 
quent coryza,  bronchitis,  pallor  with  secondary  anemia,  and  a 
tendency  to  muscular  spasm  such  as  laryngismus  stridulus,, 
nystagmus,  tetany  or  convulsions  are  noted.  Dentition  is 
delayed,  and  the  anterior  fontanelle  remains  widely  open  for 
two  years  or  longer.  Craniotabes,  thickening  of  the  bones  of 
the  forehead,  enlarged  epiphyses  at  wrists  and  ankles,  "bead- 
ing" at  the  costochondral  junctions  ("rosary"),  "pigeon"  or 
"chicken"  breast ;  "funnel"  chest,  Harrison's  groove,  green- 
stick  fractures,  knock-knee,  bowlegs,  and  kyphosis  (probably 
postural),  are  also  noted.  The  muscles  become  flabby  and 
the  ligaments  are  relaxed,  the  lymph-glands  enlarge,  as  well 


474       DISEASES    OF    METABOLISM    AND    NUTRITION. 

as  the  liver  and  spleen,  and  the  abdomen  becomes  prominent 

("pot-belly"). 

While  rickets  itself  is  never  fatal,  infants  with  rickets  seem 
very  prone  to  take  other  infections,  and  to  die  from  them 
rapidly. 

TREATMENT. 

As  properly  fed  babies  do  not  develop  rickets,  every  baby 
should  be  fed  upon  breast-milk,  or  upon  a  well-balanced  cows' 
milk  mixture,  given  in  proper  quantities  at  regular  intervals. 
It  is  important  that  the  pregnant  woman  and  the  nursing 
mother  learn  to  eat  enough  nourishing  food,  and  to  drink 
sufficient  water.  Babies  should  not  be  weaned  until  9  or  10 
months  old,  nor  should  breast-feeding  be  continued  longer 
than  one  year.  When  the  mother's  milk  supply  begins  to 
fail,  it  should  be  supplemented  by  a  bottle  given  regularly 
after  both  breasts  every  three  or  four  hours. 

For  infants  over  1  year  of  age  a  gradually  increasing 
variety  of  other  foods,  with  a  gradual  diminution  in  the 
amount  of  milk  given,  will  prevent  rickets.  Such  foods  may 
be  well-cooked  cereals,  strained  at  first;  stale  bread  or  toast 
with  butter;  fruit  juices  and  stewed  fruits;  baked  and  mashed 
potatoes  with  butter;  well-cooked  green  vegetables;  soft- 
boiled  eggs;  and  a  little  meat,  well  chopped  up,  two  or  three 
times  a  week.  Beef-juice,  meat-soups  and  meat-broths  are 
valueless,  and  may  be  even  harmful.  Babies  should  neither 
be  overfed  nor  underfed. 

Regular  bathing  in  lukewarm  or  cool  water  (80°  to  90° 
F.,  27°  to  30°  C.)  ;  much  fresh  air  and  sunlight;  enough, 
and  not  too  much,  clothing,  are  all-important.  Care  should 
be  exercised  to  prevent  the  occurrence  of  any  illness,  espe- 
cially respiratory  and  digestive  disturbances. 

As  all  active  rickets  have  ceased  when  the  child  reaches 
the  age  of  2  years,  treatment  will  only  be  valuable  earlier. 
Whatever  trace  of  rickets  remains  after  2  years  of  age  will, 
of  itself,  disappear  as  the  child  grows  older,  always  excepting 
the  severe  deformities. 

DIET. 

When  the  breast-fed  baby  develops  rickets,  the  mother 
must  take  enough  nourishment  and  exercise  out-of-doors ;  the 


RICKETS    (RACHITIS).  475 

baby  must  be  fed  regularly,  not  too  fast,  not  too  much,  and 
not  too  often.  The  breast-fed  baby  should  receive  no  other 
food ;  nothing-  else  except  4  or  5  teaspoonfuls  of  hot-water 
about  one  hour  before  nursing. 

When  the  bottle-fed  baby  develops  rickets,  the  formula 
must  be  changed,  giving  a  certified  milk  mixture  containing 
enough  protein,  a  gradual  increasing  percentage  of  fat,  and 
not  too  much  sugar.  In  severe  cases  in  very  young  infants, 
a  wet-nurse  is  advisable.  In  the  baby  of  10  months  or  more, 
a  rapid  change  to  the  varied  diet,  with  less  milk,  is  always 
best. 

HYGIENE. 

Babies  with  rickets  need  abundant  fresh  airland  sunlight. 
For  this  nothing  can  approach  the  beneficial  effect  of  the  sea- 
shore, even  in  winter.  A  change  of  air  alone,  from  city  to 
seashore,  or  country,  is  always  followed  by  rapid  improve- 
ment. 

The  regular  daily  bath  is  best  given  in  salt  water,  luke- 
warm or  cool.  In  some  cases  cold  sponging  is  of  great  value. 
In  either  case,  the  bath  should  be  followed  by  rubbing  the 
extremities  and  spine  with  olive  oil  or  cocoa-butter.  This 
affords  the  slight  massage  necessary  to  overcome  the  muscle 
relaxation.  In  a  few,,  more  advanced  cases,  passive  move- 
ments, resistant  exercises,  and  even  electricity,  are  indicated. 
In  older  children,  without  deformity,  exercises,  even  walking, 
are  to  be  encouraged. 

DRUGS. 

The  only  drugs  of  any  value  in  the  treatment  of  rickets 
are  codliver  oil  and  phosphorus.  These  are  best  combined, 
using  ^50  to  YiQQ  grain  (0.00026  to  0.00065  Gm.)  of  phosphorus 
to  5^  to  1  dram  (1.90  to  3.75  mils)  of  a  50  per  cent,  emulsion 
of  pure  codliver  oil,  given  three  times  a  day  after  meals.  The 
phosphorus  may  be  used  alone  in  some  cases.  A\nien  there 
is  marked  anemia,  iron  may  be  added  to  these,  either  as  the 
pyrophosphate  (M,  M-.  or  ^  grain;  0.01620,  0.02160  or  0.03240 
Gm.),  or  the  syrup  of  the  iodid  (5  to  15  drops;  0.32  to  0.92  mil). 

When  the  baby's  appetite  is  poor,  tincture  of  nux  vomica 
(3  to  7  drops;  0,18  to  0.42  mil)  will  be  of  great  value,  preferably 


476       DISEASES    OF    METABOLISM    AND    NUTRITION. 

in  combination  with  an  equal  quantity  of  bicarbonate  of  soda 
and  twice  as  much  compound  infusion  of  gentian,  given  three 
times  a  day  before  meals,  with  water. 

Constipation  is  overcome  by  regulating  the  baby's  milk 
formula,  giving  fruit  juices  and  stewed  fruit,  and  by  using  a 
soap  suppository,  since  most  of  these  infants  simply  seem_ 
unable  to  start  defecation.  When  a  laxative  is  needed  besides, 
magnesium  sulphate  (>4  to  1  teaspoonful  [1.90  to  3.75  mils] 
in  2  or  3  teaspoonfuls  [7.50  to  11.25  mils]  of  distilled  water), 
or  milk  of  magnesia  (>4  to  2  fa;  1.90  to  7.50  mils),  will  help. 

Olive  oil,  lime-salts,  even  phosphates  and  organotherapy 
have  all  proved  useless  in  the  treatment  of  rickets. 

When  there  is  a  marked  tendency  to  muscle-spasm  (spas- 
mophilia) ,  a  hot  bath,  hot  pack  or  mustard  bath^  with  a  laxa- 
tive, may  help.  Rarely  small  doses  of  bromids  are  useful  at 
bedtime. 

As  the  kyphosis  is  primarily  postural,  keeping  the  baby 
on  its  back  and  not  allowing  it  to  sit  up  much  will  gradually 
bring  about  recovery.  Splints,  casts,  or  braces  may  be  of 
value  for  the  bow-legs  or  knock-knees  later,  but  at  first  mas- 
sage alone  will  accomplish  much.  Gymnastics  are  good  to 
overcome  chest  deformities ;  and  in  later  childhood  (5  to  8 
years  of  age)  the  severe  bony  deformities  may  require  surgical 
intervention. 

CONGENITAL    RICKETS. 

Holt  and  Howland'^*^  state  that  there  is  probably  no  such 
condition,  although  a  congenital  type  has  been  described  on 
the  Continent,  and  attributed  to  malnutrition  and  to  chronic 
disease  in  the  mother.  Investigations  do  not  show  that  babies 
are  born  with  rickets,  but  one  may  believe  that  a  tendency 
or  predisposition  to  the  development  of  rickets  exists  as  a 
congenital  defect.^^ 

LATE    RICKETS. 
(Rachitis   Tarda;    Adolescent    Rickets), 

This  is  also  not  found  in  the  United  States,  but  has  been 
described  abroad.  It  usually  occurs  in  girls  at  the  age  of 
puberty,  and  affects  the  lower  extremities  and  the  spine  espe- 


OBESITY.  477 

cially,  producing  much  pain  and  great  deformity.  A  "rosary," 
enlargement  of  the  epiphyses,  scoHosis,  asymmetric  deformi- 
ties of  the  legs,  headache,  and  marked  physical  and  intel- 
lectual torpor  are  noted.  While  the  treatment  is  exclusively 
orthopedic,  Marfan^^  claims  results  from  adrenalin,  using  15 
to  20  drops  of  a  1 :  1000  solution  three  times  daily. 

OBESITY. 

Obesity  was  not  unknown  even  to  the  ancient  Greeks,  in 
spite  of  their  love  for  grace  of  form  and  devotion  to  gym- 
nastic exercise.  Hippocrates  (according  to  Immermanj  for 
corpulence  advised  a  scanty  diet,  cold  baths,  and  exposure  of 
the  unclothed  body  to  the  open  air.  A  similar  mode  of  treat- 
ment is  said  to  be  consciously  practised  on  the  coast  of  Italy, 
but  in  this  country  the  combination  of  exposure  to  the  open 
air  and  bathing  has  not  acquired  any  reputation  as  a  reduc- 
ing measure.  The  modern  interest  in  obesity  dates  in  a 
rough  way  from  the  time  of  Banting,  who,  in  an  open 
"Letter  on  Corpulency"  (London,  1863),  narrated  how  his 
physician  (Dr.  William  Harvey)  had  cured  him  of  this  dis- 
tressful malady  by  means  of  a  diet  as  pleasant  as  it  was 
effectual.  This  ingenuous  epistle,  while  it  aroused  much 
merriment,  created  a  tremendous  vogue  for  reduction  cures. 
The  subsequent  regimes  of  Ebstein,  German  See,  Oertel,  von 
Noorden,  Moritz  (Karell),  and  others,  have  been  based  in  a 
continually  increasing  measure  on  the  fundamental  studies  of 
nutrition,  inaugurated  by  Voit  and  continued  by  Ruebner, 
Atwater,  Chittenden,  and  a  host  of  others.  The  admirable 
monograph  of  von  Noorden'^^  ^nd  the  recent  review  of 
Matthes-*^^  contain  complete  bibliographies.  The  author  is 
indebted  to  von  Noorden's  work  for  many  of  the  facts  em- 
bodied in  this  article. 

Simple  or  alimentary  obesity  (Fettleibigkeit)  may  be 
defined  as  an  undue  accumulation  of  adipose  tissue,  due  to 
an  immoderate  ingestion,  relative  or  absolute,  of  carbonaceous 
foods  (fats,  sugars  and  starches).  This  fatty  accumulation  is 
more  or  less  uniformly  distributed  throughout  the  subcutane- 
ous connective  tissues,  in  the  mediastinum,  mesentery,  omen- 
tum, and  in  and  about  the  principal  organs.     Von  Noorden 


478       DISEASES    OF    METABOLISM    AND    NUTRITION. 

divides  this  type  of  obesity,  which  he  designates  as  "exogen- 
ous," into  forms  due  to  (1)  overeating,  (2)  lack  of  exercise, 
or  (3)  to  a  combination  of  both  factors.  A  large  proportion 
of  all  cases  of  excessive  corpulence  fall  under  this  caption, 
and  are  susceptible  to  simple  measures :  restriction  of  diet, 
exercise  (climbing,  gymnastics,  sports),  baths,  etc.  The  diet 
must  be  reduced  to  a  figure  which  will  cause  a  slight  ex- 
cess of  expenditure  over  income,  or  the  output  of  heat  and 
energy  must  be  increased  tO'  a  sufficient  extent  to  attain  the 
same  end. 

Closely  allied  to  the  cases  of  simple  obesity  are  certain 
exceptional  ones  which  do  not  yield  readily,  or  at  all,  to 
dietetic  restrictions,  even  in  the  hands  of  experts.  This  group 
is  variously  designated  by  clinicians  as :  endogenous,  constitu- 
tional, glandular,  arthritic,  or  toxi-infectious  obesity  (Fett- 
sucht).  It  is  held  by  some  authors  that  there  is  a  qualitative 
alteration  in  metabolism,  due  to  an  "arthritic  diathesis,"  to 
anomalies  of  the  internal  secretions,  or  to  toxins  {e.g.,  after 
typhoid  fever).  It  is  more  satisfactory,  however,  to  explain 
these  cases  by  assuming  an  unusual  economy  in  all  the 
life  processes,  rather  than  any  deviation  from  the  ordinary 
principles  of  metabolism.  Thus  it  is  quite  certain  that  the 
external  movements  incident  to  an  ordinary  quiet  life,  differ 
enormously  in  persons  of  varying  temperaments  under  ap- 
proximately identical  conditions.* 

A  third  division  of  obesity  comprises  certain  well-defined 
syndromes,  the  so-called  lipomatoses,  which  are  characterized 
by  a  peculiar  disposition  of  adipose  tissue,  disorders  of  the 
endocrine  glands,  and  nervous  symptoms.  The  most  impor- 
tant of  these  lipomatoses  are  Dercum's  disease  (adiposis 
dolorosa)  and  Frohlich's  syndrome  (degeneratio  adiposo-geni- 
talis). 

It  is  a  good  clinical  rule  to  treat  the  cases  comprised  under 
the  first  two  headings  (exogenous  and  endogenous)  as  exo- 
genous obesity  until  therapeutic  failure  or  distinct  evidences 
of  glandular  insufficiency  place  them  definitely  in  the  second 
class.     It  is  sufficiently  evident  that  the  deposition  of  fat  in 


*  This  can  be  tested  roughly  by  the  use  of  a  pedometer. 


OBESITY.  479 

itself  presents  nothing  abnormal,  and  only  becomes  distinctly 
pathologic  when  it  interferes  with  the  normal  activity  of  the 
patient  or  seriously  impairs  the  functions  of  important  organs. 
In  the  milder  cases  personal  whims,  fashion,  or  custom  fix 
the  limits  between  embonpoint  and  undue  corpulence.  Ameri- 
cans in  the  past  were  generally  credited  with  being  a  spare, 
wiry  people — due  primarily,  no  doubt,  to  the  active  life  char- 
acteristic of  a  new  country — and  we  still  prefer  the  slender 
types.  This  is  in  marked  contrast  to  some  of  the  older  coun- 
tries, where  a  moderate  degree  of  rotundity  is  evidently  looked 
upon  as  desirable.  The  physician  is  sometimes  called  upon 
to  urge  a  reduction  "cure,"  or,  at  least,  a  restriction  of  diet  in 
certain  sleek,  "contented"  individuals,  or,  on  the  other  hand, 
to  discourage  such  measures  in  young  women  who  are  ob- 
sessed with  the  idea  that  they  are  growing  fat.  As  an  aid  to 
the  determination  of  the  optimum  weight,  numerous  tables 
have  been  prepared  ostensibly  furnishing  the  physician  with 
the  normal  range  of  weight  for  any  given  age,  sex,  height,  or 
even  race  (Teuton,  Latin).  Many  of  these  are  from  life-insur- 
ance statistics,  and  are  presumably  computed  from  a  class  of 
persons  more  prosperous  and  better  fed  than  the  average  citi- 
zen. At  any  rate,  the  figures  usually  given  are  excessive,  if 
applied  to  persons  of  slender  ("gracile")  build  and  slight  mus- 
cular development.  Such  persons  would  be  quite  unwieldy 
if  they  attained  a  "normal"  weight.  A  relative  obesity  may 
also  occur  in  persons  crippled  by  disease  (arthritis),  or  de- 
formity (loss  of  a  limb). 

The  following  tables  are  used  by  the  Penn  Mutual  Life 
Insurance  Company  of  Philadelphia  (courtesy  of  Dr.  Llarry 
Toulmin,  Medical  Director)  : 

Table  of  Heights  and  Weights  at  Varying  Ages. 
(The  bold-faced  figures  are  20  per  cent,  over  and  under  the  average). 

Men. 


Ages 
Ft. 

'  in.' ' ' 

...15-24 

25-29 

30-34 

35-39 

40-44 

45-49 

50-54 

.55-59 

60-64 

5 

0.. 

. .  96 
120 
144 

100 
125 
150 

102 

128 
154 

105 

131 
157 

106 
133 
160 

107 

134 
161 

107 
134 
161 

107 
134 
161 

105 
131 
157 

5 

1.. 

..  98 

122 
146 

101 

126 
151 

103 

129 
155 

105 
131 
157 

107 

134 
161 

109 

136 
163 

109 

136 
163 

109 

136 
163 

107 
134 
161 

480       DISEASES    OF    METABOLISM    AND    NUTRITION. 

Table  of  Heights  and  Weights  at  Varying  Ages. 
(The  bold-faced  figures  are  20  per  cent,  over  and  under  the  average). 

Men. 


Ages 
Ft 

5 

"'in.'" 

2... 

...15-24 

.  99 

124 
149 

25-29 

102 

128 
154 

30-34 

105 

131 
157 

35-39 

106 
133 
160 

40-44 

109 
136 
163 

45-49 

110 
138 
166 

50-54 

110 
138 
166 

55-59 

110 
138 
166 

60-64 

110 
137 
164 

65-69 

5 

3... 

.  102 

127 
152 

105 

131 
157 

107 
134 
161 

109 

136 
163 

111 
139 
167 

113 
141 
169 

113 

141 
169 

113 
141 
169 

112 
140 
168 

112 
140 
168 

s 

4... 

.  105 

131 
157 

108 

135 
162 

110 
138 
166 

112 
140 
168 

114 
143 
172 

115 

144 
173 

116 

145 
174 

116 

145 
174 

115 

144 
173 

114 
143 
172 

5 

5... 

..  107 
134 
161 

110 
138 
166 

113 
141 
169 

114 

143 
172 

117 
146 
175 

118 

147 
176 

119 

149 
179 

119 

149 
179 

118 

148 
178 

118 

147 
176 

5 

6... 

.  110 

138 
166 

114 
142 
170 

116 
145 
174 

118 

147 
176 

120 

150 
180 

121 
151 
181 

122 
153 
184 

122 
153 
184 

122 
153 
184 

121 

151 
181 

5 

7... 

..  114 
142 
170 

118 

147 
176 

120 

150 
180 

122 
152 
182 

124 

155 
186 

125 

156 
187 

126 
158 
190 

126 
158 
190 

126 

158 
190 

125 
156 
187 

5 

8.. 

..  117 
146 
175 

121 

151 
181 

123 

154 
185 

126 
157 
188 

128 

160 
192 

129 
161 
193 

130 
163 
196 

130 
163 
196 

130 
163 
196 

130 

162 
194 

5 

9.. 

..  120 
150 
180 

124 

155 
186 

127 
159 
191 

130 
162 
194 

132 
165 
198 

133 
166 
199 

134 
167 
200 

134 
168 
202 

134 
168 
202 

134 
168 
202 

5 

10.. 

..  123 
154 
185 

127 
159 
191 

131 

164 
197 

134 
167 
200 

136 
170 
204 

137 
171 
205 

138 

172 
206 

138 

173 
208 

139 

174 
209 

139 

174 
209 

5 

11.. 

.,  127 
159 
191 

131 

164 
197 

135 
169 
203 

138 

173 
208 

140 

175 
210 

142 

177 
212 

142 

177 
212 

142 

178 
214 

144 

180 
216 

144 
180 
216 

6 

0.. 

..  132 
165 
198 

136 
170 
204 

140 
175 
210 

143 
179 
215 

144 
180 
216 

146 
183 
220 

146 
182 
218 

146 
183 
220 

148 
185 
222 

148 

185 
222 

6 

1.. 

..  136 
170 
204 

142 
177 
212 

145 

181 
217 

148 
185 
222 

149 
186 
223 

151 
189 
227 

150 

188 
226 

151 

189 
227 

151 
189 
227 

151 

189 
227 

6 

2.. 

..  141 
176 
211 

147 
184 
221 

150 
188 
226 

154 
192 
230 

155 
194 
233 

157 
195 
235 

155 
194 
233 

155 
194 
233 

154 
192 
230 

154 
192 
230 

6 

3.. 

..  145 

181 
217 

152 
190 
228 

156 
195 
234 

160 
200 
240 

162 
203 
244 

163 
204 
245 

161 
201 
241 

158 
198 
238 

... 

OBESITY. 


481 


Table  of  Heights  and  Weights  at  Varying  Ages. 
(The  bold-faced  figures  are  20  per  cent,  over  and  under  the  average). 


Women. 

Ages 
Ft. 

4 

'in.' ' ' 
11., 

...15 

.  83 

104 
125 

20 

87 
109 
130 

25 

90 

113 
135 

30 

93 

116 
139 

35 

95 

119 
143 

40 

98 

122 
147 

45 

100 

125 
150 

50 

102 

127 
153 

55 

103 

129 
155 

5 

0.. 

,  85 

106 
127 

89 

111 
133 

92 
115 
138 

95 
118 
142 

97 
121 
146 

100 

125 
150 

102 

128 
153 

104 
130 
156 

106 
132 
158 

5 

1.. 

,  87 
109 
131 

91 

114 
136 

94 
117 
141 

97 
121 
145 

99 

124 
149 

102 

128 
153 

105 

131 
157 

107 
133 
160 

108 

135 
162 

5 

2.. 

89 

112 
134 

93 
117 
140 

96 

120 
144 

99 

124 
148 

102 

127 
153 

104 

131 
157 

107 
134 
160 

109 

136 
163 

111 

139 
166 

5 

3., 

,  91 
114 
137 

95 

119 
143 

98 

123 
148 

101 

127 
152 

104 
130 
156 

107 
134 
160 

109 

137 
164 

112 

139 
167 

113 

141 
170 

5 

4., 

,  94 
117 
140 

98 

122 
147 

101 
126 
151 

104 

130 
156 

107 
133 
160 

110 
137 
164 

112 
140 
168 

114 

143 
171 

116 
145 
174 

5 

5.. 

.  96 

120 
144 

100 
126 
151 

104 
130 
156 

107 
133 
160 

110.. 

137 

164 

113 
141 
169 

116 

144 
173 

118 
147 
176 

119 
149 
179 

5 

6., 

,  99 
123 
148 

103 
129 
155 

107 
133 
160 

110 
137 
164 

113 
141 
169 

116 
145 
173 

118 
148 
178 

121 
151 
181 

123 
153 
184 

5 

7.. 

,  102 

127 
152 

106 
133 
159 

110 
137 
164 

113 
141 
169 

116 

145 
174 

118 

148 
177 

122 

152 
183 

124 
155 
186 

126 
158 
190 

5 

8.. 

,  105 
131 
157 

109 

137 
164 

113 

141 
169 

116 

145 
174 

120 

149 
179 

123 

154 
184 

126 

157 
189 

128 

161 
193 

131 
163 
196 

5 

9.. 

,  108 
135 
162 

113 

141 
169 

116 

146 
175 

120 

150 
180 

123 

154 
185 

127 

158 
190 

130 

162 
195 

133 
166 
199 

136 
169 
202 

In  the  absence  of  tables  the  simple  rule  popularized  by 
Moritz  may  be  used  to  approximate  the  weight.  There  are 
more  complex  formulas,  but  as  they  all  include  variables,  their 
advantages  do  not  counterbalance  their  complexity.  JMoritz 
subtracts    100    from    the    height,    expressed    in    centimeters, 

31 


482       DISEASES    OF   METABOLISM    AND    NUTRITION. 

and  takes  the  balance  as  a  measure  of  the  weight  in  kilo- 
grams.* 

The  normal  weight  varies  with  age  and  sex;  thus,  at  a 
certain  stage  of  adolescence  girls  exceed  boys  in  height  and 
weight,  while  before  and  after  the  reverse  is  true.  Children 
and  adolescents  are  occasionally  obese ;  this  may  be  a  mani- 
festation of  cretinism  or  myxedema,  but  is  more  frequently 
the  result  of  dietetic  errors.  Young  adults  continue  to  in- 
crease in  weight  till  a  maximum  is  reached  in  middle  age 
("fat  and  forty").  In  advanced  age  there  is  likely  to  be  a 
slight  decline.  Women  are  more  subject  to  obesity  than  men. 
Their  indoor  occupations  entail  less  expenditure  of  energy 
than  the  outdoor  activities  of  the  other  sex.  During  preg- 
nancy and  lactation,  moreover,  the  deposition  of  fat  is  an 
important  conservative  function  which  is  sometimes  encour- 
aged beyond  the  bounds  of  reason.  With  advanced  years  and 
the  advent  of  the  menopause,  physiologic  demands  are  much 
diminished,  but  the  acquired  surplus  is  likely  to  persist.  The 
prevalence  of  obesity  in  women  may  be  due,  in  part,  to  their 
fondness  for  sweets.  The  influence  of  heredity  is  very  evi- 
dent in  certain  families,  or  even  in  whole  races  (Jewish). 
Anders  asserts  that  heredity  was  distinctly  traceable  in  more 
than  60  per  cent,  of  his  cases  of  obesity.  Von  Noorden  sug- 
gests that  dietetic  and  culinary  habits  may  be  handed  down 
from  generation  to  generation — naturally  on  the  female  side — 
and  of  themselves  suffice  to  account  for  the  prevalence  of 
unusual  rotundity  in  certain  families. 

The  chief  hygienic  factors  concerned  in  the  production  of 
obesity  may  be  comprised  under  the  headings  food,  drink  and 
physical  activity.  In  certain  occupations  several,  or  all,  of 
these  factors  are  combined  with  maximal  effect.  The  quality 
and  quantity  of  the  food  must  be  considered.  Protein  has 
little  or  no  influence  on  the  deposition  of  fat,  but  carbohy- 
drates, and  to  a  less  extent,  fats  are  of  dominating  importance. 
Alcoholic  beverages,  particularly  those  rich  in  saccharin  deriv- 
atives (sweet  wines  and  malt  liquors),  are  very  conducive  to 


*  If  the  height  is  known  in  inches  divide  by  0.3937  to  convert  into  centi- 
meters;  if  the  weight  be  found  in  kilograms  multiply  by  2.2  to  obtain 
pounds.  For  example  a  man  of  67  inches  in  height  or  170  centimeters 
should  weigh  70  kilograms  or  154  pounds. 


OBESITY.  483 

an  increase  of  weight.*  Alcohol  in  itself  has  a  high  caloric 
value  (7  calories  per  gram),  and  if  consumed  in  moderate 
amounts  may  be  completely  utilized,  thus  sparing  an  appre- 
ciable amount  of  fat  and  carbohydrate.  The  effect  of  an 
excessive  fluid  intake  is  more  questionable. 

Simple  obesity  is  not  a  disease,  but  merely  an  exaggera- 
tion of  a  normal  state,  and  if  uncomplicated  is  unaccompanied 
by  symptoms,  except  those  due  to  mechanical  causes.  Exces- 
sive weight  interferes  with  walking  and  other  movements, 
and  induces  slight  dyspnea  on  account  of  the  increased  work 
thrown  upon  the  heart  and  lungs.  There  is  also  a  tendency 
to  free  perspiration.  If  the  deposits  are  localized,  about  the 
heart,  for  example,  there  may  be  more  serious  disturbances 
of  function.  In  persons  of  a  gastroptotic  habit,  a  localized 
deposit  of  fat  in  the  mesentery  and  abdominal  wall  may  be 
decidedly  beneficial.  The  deposition  of  fat  is  not  uniform, 
even  in  simple  obesity,  i.e.,  certain  localities  are  more  likely 
to  suffer  than  others.  While  the  feet,  hands,  and  face  are 
often  spared,  the  abdominal  wall,  and  in  women  the  buttocks, 
thighs  and  breasts  are  sites  of  predilection.  In  the  endogen- 
ous forms  of  obesity  there  is  a  qualitative  difference  in  the 
fatty  infiltration  which  tends  to  invade  the  muscular  fibers, 
cardiac  or  skeletal,  and  this  may  seriously  compromise  their 
function.  Obesity  tends  to  persist  indefinitely,  though  it  may 
occasionally  disappear  spontaneously  in  old  age.  While  not 
in  itself  serious,  it  frequently  predisposes  to  other  diseases, 
so  that  obese  subjects,  on  the  average,  are  shorter-lived  than 
those  of  sparer  habits. 

Subjects  of  obesity  may  be  of  phlegmatic  temperament, 
but  if  this  tendency  be  unduly  marked  it  should  suggest  the 
possibility  of  thyroid  insufficiency.  Similarly  neuralgia  and 
hyperesthesia  should  make  one  think  of  Dercum's  disease. 
Apoplexy  is  not  an  uncommon  terminal  event;  it  is  to  be 
attributed  to  concomitant  vascular  disease. 

Anemia  predisposes  to  fat  accumulation,  and  there  is  a 
well-marked  type  of  anemic  obesity  which  is  to  be  contrasted 
with  the  "plethoric"  or  "full-blooded"  type.     In  such  cases 


*  Banting  considered  the   following  articles  particularly  conducive   to 
obesity :   bread,  butter,  sugar,  potatoes,  milk,  beer,  port  and  champagne. 


484       DISEASES    OF    METABOLISM    AND    NUTRITION. 

tonics    are    essential,    and    extreme    reduction    measures    are 
inadvisable. 

There  is  a  close  relation  between  obesity  and  disturbances 
of  the  glands  of  internal  secretion.  Certain  other  glands 
which  primarily  have  an  external  secretion,  the  pancreas, 
testicles  and  ovaries,  are  capable  of  exerting  similar  effects. 
Hyperfunction  of  the  thyroid  tends  to  increase  metabolism 
and  to  induce  loss  of  weight,  while  hypofunction,  as  seen  in 
an  exaggerated  degree  in  myxedema  and  cretinism,  leads  to 
an  increased  deposition  of  fat.  Symptoms  which  should  sug- 
gest a  thyroid  element  in  a  given  case  are  somnolence,  alope- 
cia, dryness  of  the  skin,  cold  feet  and  hands,  and  diminished 
sweating.  In  hypopituitarism  obesity  is  associated  with  mal- 
development  of  the  sexual  organs,  scanty  or  atypical  hair 
distribution,  and  large  breasts  (in  the  male).  The  influence 
of  the  sexual  glands  on  fat  distribution  is  manifested  by  the 
normal  differences  in  the  two  sexes,  as  well  as  by  those 
changes  which  result  from  castration,  •  Conversely,  lessened 
sexual  desire,  impotence,  scanty  menstruation,  and  sterility 
are  credited  to  excessive  obesity.  In  eunuchs  there  is  a 
marked  liability  to  an  obesity  which  partakes  of  the  female 
type.  It  is  a  question  whether  the  well-recognized  tendency 
to  fleshiness  in  women  who  have  been  deprived  of  their 
ovaries  by  operation,  or  have  reached  the  menopause,  is  to 
be  attributed  to  the  withdrawal  of  glandular  influence  or  to 
extraneous  causes.* 

The  relation  between  obesity  and  diseases  of  the  heart  is 
a  close  one.  Simple  obesity  may  lead  to  cardiac  embarrass- 
ment and  ultimately  to  hypertrophy  and  dilatation,  on  account 
of  the  excessive  accumulation  of  fat  in  and  about  the  heart. 
On  the  other  hand,  primary  cardiovascular  disease  is  often 
complicated  by  obesity.  The  best  results  from  reduction 
cures,  fluid  limitation,  hydrotherapy,  graduated  exercises,  and 
the  like,  are  observed  in  cases  of  obesity  complicated  by 
cardiac  disease. 

In  diseases  of  the  respiratory  system  overweight  is  often 
of  serious  import,  on  account  of  the  burden  thrown  upon  the 


*  A  German  author  recently  followed  up  his  cases  of  oophorectomy,  and 
was  unable  to  determine  any  special  tendency  to  fat  accumulation. 


OBESITY.  485 

respiratory  as  well  as  the  circulatory  organs.  It  is  a  serious 
complicating  factor  in  pneumonia,  chronic  bronchitis,  emphy- 
sema, asthma,  and  even  in  pulmonary  tuberculosis.  In  the 
last-named  disease  overfeeding  may  lead  to  an  anemic  type 
of  obesity,  which  cannot  be  considered  a  valuable  asset  to  the 
patient. 

Obese  subjects  frequently  possess  an  unusually  good  diges- 
tion and  power  of  assimilation.  This  probably  accounts  for 
their  ability  to  gain  on  a  diet  which  is  apparently  not  exces- 
sive. Disturbances  of  the  digestive  system  are  not  common. 
The  liver  is  occasionally  enlarged  as  the  result  of  fatty 
infiltration. 

Renal  complications  include  passive  congestion  of  the  kid- 
neys and  chronic  diffuse  nephritis.  Both  are  usually  asso- 
ciated with  cardiovascular  disease.  Diseases  of  the  muscles, 
bones  and  joints  bear  no  direct  relation  to  excessive  corpu- 
lence, but,  if  disabling,  may  act  as  predisposing  causes,  by 
limiting  motion  and  reducing  the  output  of  energy.  Skin 
complications,  chiefly  intertrigo  and  eczema,  are  common  on 
account  of  the  apposition  of  fat-laden  folds  of  skin,  for 
example,  beneath  the  breasts.  After  rapid  weight  reduction, 
unsightly  "striae"  are  observed  upon  the  breasts,  abdomen  and 
thighs.  Finally,  obesity  is  frequently  complicated  by  other 
metabolic  disturbances,  particularl}^  gout  and  glycosuria. 
This  is  sufficiently  accounted  for  by  the  similarity  of  the 
predisposing  causes :  overeating,  overdrinking,  lack  of  exer- 
cise, and  similar  dietetic  defects. 

French  authors  describe  an  arthritic  diathesis  which  they 
believe  predisposes  to  a  large  group  of  closely  related  dis- 
eases: obesity,  gout,  diabetes,  nephritis,  stone,  migraine, 
asthma,  neurasthenia,  eczema,  acne,  purpura  and  urticaria. 
To  most  of  us  the  connection  between  these  varied  conditions 
is  not  so  obvious,  although  occasionally  it  is  supported  by 
therapeutic  observations. 

TREATMENT. 

Prophylaxis.  The  preventive  treatment  of  obesity  is  more 
important,  and  more  effectual  than  the  curative  treatment.  In 
childhood  and  old  age  it  is  usually  the  only  safe  method  of 
attack.     It  is  the  duty  of  the  physician  to  warn  adult  patients 


486       DISEASES    OF   METABOLISM    AND    NUTRITION. 

who  are  tending  to  overweight  of  the  possible  injury  to  the 
circulatory  or  other  systems,  and  after  investigation  of  habits 
and  diet  to  suggest  appropriate  measures  of  prevention. 
These  may  suffice  to  check  further  increment.  In  children 
the  general  rule  is  to  avoid  any  severe  measures  of  reduction, 
and  particularly  any  restriction  of  protein  food,  as  this  may 
interfere  with  proper  development.  The  child's  diet  should 
be  studied  from  carefully  written  records  kept  by  the  mother 
or  other  observer.  In  many  cases  gross  dietetic  errors  will 
thus  be  discovered,  usually  an  excessive  ingestion  of  sugars  and 
starches.  In  children  it  is  best  to  give  the  carbohydrates  in 
the  form  of  well-cooked  starches,  bread,  macaroni,  rice,  break- 
fast cereals,  and  plain  puddings,  rather  than  in  the  form  of 
cakes,  sugars,  candies  and  other  sweets.  In  these  cases,  as 
in  the  treatment  of  obesity  generally,  the  diet  should  be 
adjusted  to  the  normal  weight  for  the  age  and  height,  rather 
than  to  the  actual  weight.  The  allotment  of  protein  should 
be  ample  to  provide  for  the  growing  organism,  and  to  guard 
against  the  robbing  of  the  body  protein,  which  is  liable  to 
occur  with  even  slight  restriction  of  carbonaceous  foods.  In 
adolescence  mild  reduction  cures  carried  out  under  close  sur- 
veillance are  admissible. ^^ 

Exercise  plays  a  more  important  role  in  children  and 
adolescents  than  in  adults,  and  in  cases  uncomplicated  by 
cardiac  weakness  it  should  be  encouraged  to  the  fullest  extent. 
Open-air  sports,  such  as  swimming,  rowing,  walking,  running, 
bicycling,  basket-ball,  base-ball  and  tennis  are  far  preferable 
to  indoor  gymnastics.  Exercise  develops  the  muscular  sys- 
tem at  the  cost  of  the  fatty  tissues,  and  even  if  obesity  per- 
sists, it  is  less  serious  in  the  well-muscled  than  in  the  flabby, 
anemic  individual. 

In  a  small  proportion  of  obese  children,  careful  scrutiny 
will  elicit  symptoms  of  hypothyroidism  or  dispituitarism. 
For  the  latter  there  is  no  satisfactory  specific  treatment.  In 
hypothyroidism  (cretinism)  excellent  results  may  be  obtained 
by  the  use  of  dried  thyroids  given  in  small  doses,  %  grain 
(0.2  Gm.)  three  times  a  day,  and  increased  if  well  borne.  If 
the  diagnosis  has  been  well  grounded,  remarkable  results  may 
be  expected.  In  the  aged,  severe  restriction  of  diet,  active 
exercise  and  hydrotherapeutic  measures  are  alike  inadmissible. 


OBESITY.  487 

The   diet  may  be  kept  within   normal   bounds,   and   physical 
measures  such  as  massage  and  passive  movements  employed. 

THE    TREATMENT    OF    UNCOMPLICATED    OBESITY 
IN    ADULTS. 

General  Principles.  The  caloric  requirements  of  adults 
under  varying  conditions  have  been  considered  in  the  intro- 
ductory chapter  on  Metabolism  {y.  s.).  For  men  and  women 
pursuing-  a  life  of  moderate  activity,  but  without  excessive 
labor,  approximately  35  calories  per  kilogram  (correspond- 
ing to  16  calories  per  pound)  are  ordinarily  sufficient.  In 
obesity  it  is  necessary  to  reduce  the  caloric  intake  with  or 
without  increasing  the  energy  output.  This  should  be  done 
by  reducing  the  carbonaceous  foods  (fats  and  carbohydrates). 
The  protein  should  be  maintained  at  its  normal  level  (1  Gm. 
per  Kg.),  or  even  increased  50  or  100  per  cent.  A  liberal 
protein  ration  is  of  practical  advantage  for  several  reasons — 
practical  and  theoretical.  (1)  It  makes  the  necessary  restric- 
tion of  other  foodstuffs  endurable.  (2)  Proteins,  even  if 
increased  beyond  the  usual  amount,  are  not  conducive  to 
increase  of  weight.  (3)  A  liberal  provision  of  protein  food 
is  a  protection  to  the  vital  tissues,  sometimes  impaired  by  too 
strict  dieting.  Thus,  if  fats,  sugars  and  starches  are  limited 
and  the  protein  ration  is  insufficient,  carbohydrate  may  be 
split  off  from  the  body  protein  and  consumed.  The  caloric 
value  of  the  diet  may  be  reduced  by  restricting  either  the 
carbohydrate  or  the  fat  indifferently,  or,  in  most  cases,  by 
limiting  both. 

The  famous  regimens  of  Banting  and  Oertel,  in  accord- 
ance with  the  ideas  of  their  day,  gave  a  very  liberal  allowance 
of  protein  (150  to  170  Gms.),  but  restricted  the  fats  and  car- 
bohydrates very  closely.  They  resemble  a  strict  diabetic  diet 
without  fat.  Such  a  diet  can  easily  be  constructed  by  the 
aid  of  the  tables  given  under  "Diabetes."  Ebstein's  diet  was 
less  rich  in  protein  (100  Gms.),  but  permitted  the  use  of  a 
fairly  large  amount  of  fat  (85  Gms.).  This,  again,  is  similar 
in  principle  to  a  diabetic  diet  with  restricted  protein.  A  third, 
and  perhaps  the  best,  alternative  is  to  restrict  the  fat  more 
than  the  carbohydrate,  because  the  latter  best  prevents  loss 
of  body  protein,   and   consequent   loss  of  strength.     A  diet 


488         DISEASES  OF  METABOLISM  AND  NUTRITION. 

which  includes  a  moderate  amount  of  carbohydrate,  especially 
in  the  form  of  green  vegetables,  has  also  the  advantage  of 
bulk  or  ballast.  Thus,  in  constructing  a  dietary  it  is  usual  to 
restrict  either  the  fat  or  the  carbohydrate  predominantly.  For 
the  reasons  given  the  former  alternative  is  preferable,  though 
in  special  instances  the  patient's  preferances  may  be  consulted. 

INDICATIONS. 

The  necessity  for  reduction  and  the  character  of  the  treat- 
ment will  depend  upon  the  type  and  degree  of  obesity,  and 
upon  personal  and  social  factors.  In  the  beginning  we  may 
assume  that  a  case  is  of  the  exogenous  type,  but  if  there  is 
no  loss  of  weight  after  two  or  three  weeks  of  strict  diet  (20 
instead  of  35  or  40  calories  per  Kg.),  an  endogenous  element 
should  be  suspected.^^  The  amount  of  restriction  will  depend 
upon  the  degree  of  obesity.  Von  Noorden  classifies  cases  in 
which  the  weight  exceeds  the  normal  by  5  to  15  kilograms 
as  mild,  by  15  to  25  kilograms  as  moderate,  and  over  25 
kilograms  as  of  high  degree,  and  recommends  four-fifths  of 
the  normal  diet  in  the  first  instance,  three-fifths  in  the  second, 
and  two-fifths  in  the  third.  Thus  given  a  normal  requirement 
of  2500  calories,  2000,  1500  and  1000  calories  would  be  indi- 
cated in  the  several  varieties.  As  a  rule,  a  slow  reduction  of 
1  to  2  pounds  a  week  over  a  prolonged  period  is  preferable 
to  a  more  rapid  loss  of  weight.  The  rapid  method  usually 
requires  rest  in  bed  at  the  beginning,  and  is  suitable  for 
patients  with  an  extreme  degree  of  obesity,  or  for  those  who 
desire  to  obtain  quick  results.  Many  persons  either  do  not 
have  the  strength  of  mind  or  lack  suitable  facilities  for  carry- 
ing out  a  prolonged  course  of  treatment,  but  are  willing  to 
submit  to  periodic  terms  of  deprivation  in  a  hospital  or  at 
same  watering-place.  Facilities  for  such  forms  of  treatment 
are  less  available  here  than  abroad. 

In  the  treatment  of  a  particular  case  we  should  determine 
by  the  use  of  the  tables  and  formulae,  with  due  attention  to 
build  and  muscular  development,  what  would  constitute  a 
normal  weight  for  the  patient.  A  theoretic  diet  can  then  be 
calculated  which  should  make  the  patient  lose  a  pound  or  two 
a  week  on  the  average.    A  careful  study  of  the  patient's  pre- 


OBESITY.  489 

vious  diet  is  helpful  in  outlining  such  a  regime.  Using  this 
preliminary  diet  as  a  basis,  further  restrictions  may  be  insti- 
tuted if  required.  It  is  wise  in  a  prolonged  course  of  treat- 
ment to  interfere  with  the  patient's  habits  as  little  as  circum- 
stances will  permit.  On  the  other  hand,  more  rapid  results 
are  sometimes  attainable  by  radical  modification  of  the  diet. 
In  accordance  with  the  above  principle  a  diet  for  Americans 
should  consist  of  three  meals,  with  the  possible  addition  of 
afternoon  tea.  Dinner  may  be  either  in  the  middle  of  the  day 
or  at  night,  according  to  the  patient's  previous  habit.  If 
breakfast  .and  supper  (luncheon)  are  standardized,  the  in- 
crease (or  decrease)  of  the  diet  is  simplified.  It  is  simpler 
to  construct  these  diets  by  the  caloric  method,  which,  like  the 
percentage  method  in  infant  feeding,  allows  of  a  more  uniform 
increase  and  decrease.  Unless  dependable  formulae  are  used 
(see  below)  there  may  be  doubt  as  to  the  accuracy  of  values 
obtained  (as  these  must  usually  be)  by  calculation,  not  by 
actual  analysis.  It  is  quite  possible,  indeed,  to  use  a  purely 
empiric  method,  provided  that  one  assures  one's  self  that 
necessary  elements  are  not  cut  too  low.  Whenever  possible 
the  food  should  be  weighed  at  the  table.  (Sufficiently  accurate 
scales  may  be  obtained  for  about  $15.  If  the  pans  are  not 
movable,  small  papier-mache  plates  will  be  found  useful,  as 
they  may  be  balanced  against  each  other,  and  so  do  away  with 
unnecessary  calculations.  Still  more  convenient  scales,  which 
may  be  turned  back  to  zero,  after  each  addition  of  food,  are 
on  the  market.)  This  is  of  special  value  during  the  first  few 
weeks  of  treatment  as  an  educational  matter.  After  that  the 
patient's  judgment  will  be  sufficiently  accurate  for  practical 
purposes. 

The  tables  which  follow  were  calculated  to  yield  approxi- 
mately 1000,  15C)0  and  2000  calories,  respectively,  or,  in  other 
words,  amounts  suitable  for  the  hypothetic  patient  with  a 
normal  weight  of  70  kilograms,  and  a  high,  moderate,  or 
slight  degree  of  obesity.  In  each  instance  the  number  of 
grams  of  protein,  fat  and  carbohydrate  is  stated.  The  data 
were  largely  obtained  from  Locke's  convenient  tables  ("Food 
Values"),  but  the  simple  factors  4,  9  and  4  were  used  for  cal- 
culating the  caloric  values  (per  Gm.)  of  protein  (P.),  fat  (F.) 
and  carbohydrate  (CH.)  : 


490       DISEASES    OF   METABOLISM   AND   NUTRITION. 

I. 

(Additional  articles  under  IV,  lists  1  to  4). 

Breakfast.                        Remarks.  Gms.      P.  F.  C-H.  Cal. 

Oranges    Vz     125      0.7  0.2  10.6  46  See  list  1. 

Egg    1      50      6.6  6.0  ...  80 

Butter    .' 15      0.2  12.8  ...  116 

Roll,  French  1      39      3.3  1.0  21.7  109 

Coffee    100 

Milk  (hot)    100      3.5  _  4.0  4.5  68  "Cafe  au  lait." 

Saccharin  2  gr.   (if  desired) . 

14.3  24.0  36.8  419 

Lunch  or  Supper. 

Tea  and  lemon   200 

Saccharin   2  gr.   (if  desired) . 

Cold   veal    50    14.2  '0.6  ...  62  See  list  2. 

Salad : 

Lettuce    50      0.6  0.1  2.0  11  See  list  3. 

Apple    ^      75      0.2  0.2  8.0  34  See  list  1. 

Almonds    5       1.1  2.7  0.8  32 

French  dressing   11      ...  8.0  ...  72 

Calf's  foot  jelly  50      2.2  ...  8.7  44  See  list  5. 

18.3  11.6  19.5  255 

Dinner. 

Bouillon 120      2.6  0.1  0.2  13 

Celery    50      0.5  tr.  1.6  8Seelist3. 

Roast  beef,  lean  100    23.3  1.7  ...  110  See  list  2. 

Onions    100      1.2  1.8  4.9  41  See  list  3. 

Spinach    100      2.1  4.1  2.6  56  See  list  3. 

Vz  egg  (hard)    25      3.3  3.0  ...  40 

Cottage  cheese 

(without  cream)    20      4.2  0.2  ...  19 

Stewed  strawberries 

(without    sugar)     100      1.0  0.6  7.4  39  See  list  1. 

38.2  11.5  16.7  326 

Totals  71.8  47.1  73.0    1000 


II. 

(Additional  articles  under  IV). 

Breakfast.                          Remarks.  Gms.       P.         F.  C-H.  Cal. 

Apple    1     150      0.5      0.5  16.2  72  See  list  1. 

Eggs   2     100    13.2    12.0  ...  160 

Butter  (ball)    15      0.2    12.8  ...  116 

Roll,  French  1      39      Z.Z      1.0  21.7  109 

Coffee    100 

Milk    100      3.5      4.0  4.5  68 

Sugar,  cube    7      7.0  28  "Cafe  au  lait." 

20.7    30.3  49.4  553 


OBESITY.  491 

Lunch  or  Supper.          Remarks.  Gms.      P.  F.  C-H.  Cal. 

Tea  and  lemon   200 

Sugar,  cube    7  7.0  28 

Cold  chicken    100  32.1  4.4  2.1  176  See  list  2. 

Asparagus    100  2.1  3.3  2.2  47  See  list  3. 

French   dressing   11  ...  8.0  ...  72 

Toast,  Vi  slice  10  1.2  0.2  6.1  31 


35.4  15.9  17.4  354 

Dinner. 

Oysters    6      85  5.3  1.0  3.2  43 

Celery    50  0.5  tr.  1.6  8Seelist3. 

•Mutton,  boiled,  lean    ....  100  30.9  4.5  ...  164  See  list  2. 

Squash    100  1.4  0.8  13.6  67  See  list  3. 

Spinach    100  2.1  4.1  2.6  56Seelist3. 

H   egg   25  3.3  3.0  ...  40 

Swiss  cheese    20  5.5  7.0  0.2  86 

Cantaloupe   34     232  0.7  ...  10.5  45  See  list  1. 


49.7    20.4    31.7      509 


Totals  105.8    66.6    98.6     1416 

III. 

By  the  addition  of  a  roll  and  butter  (225  calories),  a  potato 
(126  calories),  and  a  simple  dessert  such  as  soft  custard  (131 
calories)  to  the  dinner,  the  diet  (II.)  may  be  brought  up  to 
approximately  2000  (1898)  calories.  Indeed,  it  will  be  easy 
to  exceed  that  limit  if  care  in  the  choice  and  weighing-  of  the 
food  be  relaxed. 

The  following  lists*  give  the  weig^ht  and  caloric  values  of 
various  foodstuffs  which  may  be  substituted  for  the  articles 
given  in  the  diets ;  also  articles  that  should  be  avoided  or  only 
used  by  special  permission : 

IV. 

1.  Fruits.  (Fruits  may  be  stewed  without  sugar  or  be 
taken  raw).  Apple,  150  grams  =  72  calories;  blackberries, 
100  =  59;  ji  cantaloupe,  230  =  45;  cherries,  100  =  76;  cur- 
rants, 100=^59;  34  grapefruit,  150  =  69;  grapes,  75  =  56; 
huckleberries,  100^76;  ^  orange,  125=48;  peach,  125  = 
42;  y2  pear,  75  =  42;  pineapple,  50^44;  plum,  35  =  29; 
raspberries,  50  =  28;  strawberries,  100  =  40;  watermelon, 
300  =  39. 


*  Also  see  list  at  end  of  chapter  on  Metabolism. 


492       DISEASES    OF    METABOLISM    AND    NUTRITION. 

To  he  avoided:  Bananas,  dried  fruit,  preserves,  jams,  jellies 
and  marmalade. 

2.  Meats,  Fozd  and  Fish.  Beef,  roast,  very  lean,  100 
grams  =  111  "calories;  beef  "round,"  fat  removed,  100^ 
185;  sweetbread,  80=135;  chicken,  roast,  100=180;  mutton, 
boiled,  lean,  75  =  126;  mutton-chop,  lean,  100=135;  pork 
(lean  ham),  33  =  93;  cod  (boiled),  100  =  98;  haddock  (boiled), 
100=108;  halibut  (boiled),  100=121. 

To  be  avoided:  Beef  tenderloin,  tongue,  capon,  lamb,  bacon 
and  pork  in  general;  turkey,  goose,  duck,  bluefish,  mackerel, 
salmon,  and  fat  meats  in  general.  Also  hashes,  croquettes, 
sausages,  fried  meat,  etc, 

3.  Vegetables.  Artichokes,  100  grams  =  27  calories ;  as- 
paragus (canned),  125^23;  string-beans,  60=13;  beets, 
70=:  29;  beet-greens,  100  =  54;  cabbage,  100  =  5;  carrots, 
100=18;  cauliflower,  100  =  7;  celery  (raw),  50  =  9;  corn 
(canned),  100=101;  corn  (green),  100=100;  cucumbers, 
50  =  9;  dandelion-greens,  100  =  63;  mushrooms  (raw),  50  = 
23;  onions,  100  =  42;  parsnips,  100=10;  baked  potato  (spe- 
cial), 100=114;  squash,  100  =  69;  spinach,  100=57;  toma- 
toes (canned),  70^16;  tomatoes  (raw),  100  =  23;  turnips, 
100  =  4. 

To  be  avoided:  Beans  in  general,  corn,  mushrooms  (except 
raw),  peas,  potatoes  (sweet  or  white)  in  all  forms.  Also 
hominy,  rice,  and  macaroni  (often  used  as  "vegetables"), 

4.  Soups  and  Razv  Shellfish.  Beef-soup,  120  grams  =  32 
calories;  bouillon,  120=13;  consomme,  120=14;  Julienne, 
120=16;  vegetable  (canned),  120=17.  Also  raw  clams 
(round)  (6),  100  =  47;  raw  oysters  (6),  85  =  44. 

To  be  avoided:  Bean,  chicken,  green  and  mock  turtle, 
oxtail,  pea  and  tomato-soups.  Also  cream-soups,  stews  and 
chowders. 

5.  In  addition  to  articles  specifically  prohibited  above, 
avoid:  (1)  All  fatty  food — butter,  cream,  olive  oil,  etc.,  and 
all  articles  prepared  with  fat — fried  food,  pastry,  rich  sauces, 
puddings,  etc.  (2)  All  starchy  food,  including  breads,  cereals, 
desserts,  thickened  sauces  and  gravies.  (3)  Sugars  and  all 
sweets — candies,  cakes  and  desserts.  Condiments  and  sauces 
are  objectionable  ir.  proportion  to  their  content  in  sugar  or  oil. 


OBESITY.  493 

In  mild  cases  gelatin  (calf's  foot  jelly),  custards,  etc.,  pre- 
pared with  a  minimum  of  sugar  may  be  allowed. 

The  patient  should  be  weighed  once  a  week,  and  always 
at  the  same  hour.  This  should  be  several  hours  after  break- 
fast, with  bladder  and  bowels  empty.  On  the  basis  of  a  gain 
or  loss  of  weight  the  diet  should  be  readjusted.  No  mention 
has  been  made  of  fluid  restriction,  because  this  is  not  indi- 
cated in  simple  obesity.  On  the  day  before  weighing,  and  in 
any  event,  on  the  day  of  weighing,  a  uniform  amount  of  fluid 
should  be  ingested.  Following  the  active  treatment,  which 
may  last  from  a  few  weeks  to  several  months,  a  diet  not  more 
than  sufficient  to  keep  the  weight  stationary  should  be  insti- 
tuted. If,  in  spite  of  this,  there  is  a  tendency  to  gain,  fast 
days  are  indicated  (Boas)  once  a  week  or  less  frequently. 
On  these  days  Boas  allows  100  grams  of  black  bread,  2 
hard-boiled  eggs  and  an  apple.  Others  limit  the  food  to  a 
liter  of  milk. 

SPECIAL    DIETETIC    MEASURES. 

In  cases  complicated  by  cardiovascular  or  renal  disease,  as 
well  as  in  gout  and  diabetes,  special  modifications  are  desir- 
able. In  gout  the  protein  should  not  exceed  1  gram  per 
kilogram,  and  foods  rich*  in  purin  should  be  avoided.  A 
moderate  restriction  of  protein  is  also  advisable  in  nephritis. 
In  cases  with  edema,  fluid  restriction  is  of  g-reat  importance, 
and  this,  as  well  as  salt  restriction  (particularly  useful  in 
nephritis),  is  provided  for  in  some  of  the  special  dietaries. 

Karell's  diet,  originally  designed  for  the  removal  of 
dropsy,'^"^  has  been  modified  by  Moritz,  Rosenraad-^''^  Jacob, 
and  others  for  cases  of  obesity.  This  modified  diet  consists 
essentially  of  2000  mils  of  milk  for  a  person  with  a  metabol- 
ism of  2800  to  3000  calories,  and  represents  approximately  20 
calories  per  kilogram.  It  contains  very  little  salt.  A  potato, 
representing  100  calories,  is  frequently  added  to  protect  the 
protein. 

After  a  variable  time  of  a  few  days  to  a  week  or  more, 
transition  is  made  to  a  diet  poor  in  fat,  consisting  of  lean 
meat,  green  vegetables,  stewed  fruit,  and  4  to  5  ounces  (125  to 
150  Gms.)  of  graham  (black)  bread.  The  fluid  is  restricted 
to  1  quart  (1000  mils).     Other  diets  recently  suggested  for 


494       DISEASES    OF    METABOLISM    AND    NUTRITION. 

obesity  are  the  vegetarian/^^  desirable  on  account  of  the 
variety  offered,  and  the  potato  diet  (Rosenfelt),  which  is  effec- 
tive for  precisely  the  opposite  reason,  for  its  monotony  de- 
stroys any  desire  for  excessive  food.  Both  of  these  diets  are 
bulky,  and  in  this  sense  satisfying-.  The  general  principles 
underlying-  the  classic  diets  of  Oertel  and  Ebstein  have  already 
been  mentioned. 

A  modified  form  of  vegetarian  diet,  recently  prescribed  at 
a  prominent  watering-place,  consisted  of  4  glasses  of  milk 
(1  qt.),  2  glasses  of  buttermilk  (1  pt),  4  glasses  of  Vichy 
(1  qt.),  and  3  baked  potatoes  (1200  to  1350  calories).  In  this 
case  a  large  amount  of  fluid  was  allowed,  probably  because  of 
a  "gouty"  element  in  the  case. 

DRUGS. 

The  drug  treatment  of  obesity  may  be  dismissed  in  a  very 
few  words.  The  exogenous  form  requires  no  drug  treatment 
other  than  symptomatic  measures  indicated  by  special  com- 
plications, such  as  anemia,  constipation,  intestinal  flatulence, 
and  the  like.  These  should  be  treated  according  to  the  prin- 
ciples laid  down  elsewhere  in  this  work.  In  the  endogenous 
form  of  obesity,  dried  thyroids  may  be  used  with  excel- 
lent effect.  Inasmuch  as  large  doses  have  been  known  to 
bring  on  symptoms  of  hyperthyroidism  (rapid  pulse,  nervous- 
ness, loss  of  weight  and  strength),  which  are  very  difficult  to 
control,  the  dosage  at  the  beginning  should  be  very  small. 
One-half  grain  (0.03234  Gm.)  three  times  a  day  will  be  ample, 
and  may  be  cautiously  increased  up  to  the  pharmacopceial 
dose,  1^  grains  (0.1  Gm.).  This  drug  treatment  should  be 
used  in  connection  with  the  dietetic  treatment,  as  recom- 
mended for  simple  obesity.  Other  drugs,  official  or  proprie- 
tary,''^* have  been  suggested  for  this  condition,  but  none  of 
them  can  be  recommended. 

HYDROTHERAPY. 

The  daily  intake  of  water  is  often  restricted  in  obesity, 
first  for  the  purpose  of  diminishing  edema, — a  use  which  is 
well  founded, — and,  secondly,  for  the  purpose  of  reducing 
weight,  independent  of  edema.  Although  the  weight  may  be 
reduced  temporarily  by  this  measure,  it  would  seem  in  the 


OBESITY.  495 

latter  instance  to  subject  the  patient  to  the  danger  of  insuffi- 
cient elimination  with  no  compensating  advantage.  Prof. 
Kisch,  of  Marienbad,  advises  mineral  waters  containing 
Glauber's  salts.  He  is  uncertain  whether  they  act  by  increas- 
ing- CO2  consumption  and  fat  utilization,  or  merely  by  inter- 
fering with  absorption,  on  account  of  the  free  movement  of 
the  bowels.  There  seems  to  be  no  valid  indication  for  these 
waters  other  than  for  constipation  and  flatulence.  Frequently 
abdominal  distention  is  due  in  part  to  gas,  and  may  be  relieved 
by  suitable  treatment. 

Steam,  hot-air,  and  electric-light  baths,  usually  follov/ed 
by  a  cool  douche,  shower  or  plunge,  and  massage  are  widely 
used  to  reduce  flesh.  Undoubtedly  a  temporary  reduction  of 
weight  may  be  obtained  by  this  method,  but  this  is  due  solely 
to  the  loss  of  water,  and  is  of  no  value  in  the  absence  of  renal 
complication.  In  cases  with  nephritic  edema,  a  similar  but 
more  permanent  reduction  may  be  obtained  by  salt  restric- 
tion. Baths  have,  however,  undoubted  collateral  benefits, 
improving  the  condition  of  the  skin,  increasing  peripheral 
circulation,  increasing  elimination,  and  stimulating  the  heart 
and  the  nervous  system.  Prolonged  cold  baths,  combined 
with  rubbing  and  exercise,  are  theoretically  rational,  since  it 
is  evident  that  a  certain  amount  of  heat,  representing  food 
consumption,  may  thus  be  abstracted.  Gartner"*!  advises  row- 
ing movements  performed  while  in  the  cold  bath,  using  elas- 
tic-rubber tubes  (these  may  be  attached  to  the  faucet)  to  fur- 
nish the  resistance.  The  Nauheim  baths  are  used  in  obesity 
complicated  with  heart  disease,  primarily  to  improve  the  tone 
of  the  heart-muscle.  (See  Diseases,  of  the  Cardiovascular 
System,  Vol.  II.)  Baths  combined  with  vigorous  resistance 
movements,  graduated  according  to  the  strength  of  the  pa- 
tient's heart  and  general  musculature  are  now  being  used  ex- 
tensively in  our  large  cities  for  weight  reduction  in  gouty, 
overfed,  and  underexercised  business  men.  These  may  be  of 
great  benefit,  but  should  not  be  undertaken  without  prelimi- 
nary examination  of  the  heart  by  a  physician. 

Passive  exercises  are  most  suitable  for  the  aged,  and  those 
with  weak  heart.  Deep  breathing  and  active  movements  with- 
out apparatus  (Swedish  movements,  setting-up  drill)  are  use- 
ful if  systematically  carried  out.     Like  all  indoor  gymnastics. 


496       DISEASES    OF   METABOLISM    AND    NUTRITION. 

they  soon  become  irksome.  More  elaborate  gymnastic  equip- 
ment, like  the  Zander  apparatus,  is  not  usually  available 
except  in  a  few  large  cities.  Outdoor  exercise  has  the  great 
advantage  of  offering  variety,  interest,  and  the  opportunity 
of  deep  breathing  of  fresh  air.  For  middle-aged  adults  the 
most  useful  and  available  exercises  are  walking,  climbing  and 
golf.  The  automobile  is  undoubtedly  conducive  to  obesity, 
but  may  be  used  with  signal  advantage,  since  it  makes  walk- 
ing and  climbing  possible  even  for  those  who  live  in  closely 
built-up  towns.  Golf  has  hitherto  been  a  sport  for  the  well- 
to-do,  but  with  the  rapid  introduction  of  public  links  this 
pastime  is  now  becoming  available  for  the  general  public. 
Swimming  is  another  valuable  exercise.  Finally,  tennis  and 
baseball  should  be  mentioned  for  the  young  and  vigorous. 

General  massage  has  little  effect  in  reducing  obesity,  but 
many  competent  clinicians  believe  that  local  massage  of  the 
abdomen  or  hips  may  favor  a  more  desirable  distribution  of 
the  adipose  tissue.  Bergonie^^  j^^s  devised  an  electrical  appa- 
ratus by  which  muscles  in  various  regions  may  be  passively 
exercised  without  discomfort  to  the  patient.  In  this  way  it 
is  claimed  that  the  muscles  of  the  hips,  for  example,  may  be 
rapidly  reduced.  Mechanical  massage,  by  means  of  vibrators 
and  rollers,  has  been  employed  for  the  same  purpose. 

The  "Spa"  treatment  is  much  in  vogue  abroad,  Homburg, 
Kissingen,  Marienbad  and  Vichy  being  a  few  of  the  better 
known  resorts.  In  this  country  patients  at  "baths"  are  under 
a  less  close  surveillance.  There  are  suitable  facilities  for 
treatment  at  Saratoga  Springs,  N.  Y. ;  Hot  Springs  of  Virginia ; 
White  Sulphur  Springs,  West  Virginia,  and  elsewhere.  Un- 
der strict  treatment  in  such  resorts  patients  may  lose  half  a 
pound  a  day  or  more.    Such  a  rapid  loss  is  seldom  permanent. 

GOUT. 

Gout,43  a  metabolic  disorder  of  uncertain  etiology,  is 
almost  uniformly  associated  with  an  increased  amount  of 
uric  acid  in  the  blood,  and  in  long-standing  cases  with  uratic 
nodules  in  the  sul)cutaneous  tissues,  or  in  and  about  the 
joints.  This  underlying  anomaly  is  more  or  less  permanent, 
but  may  be  punctuated :   by  acute  "fits"  of  arthritis  (arthritis 


GOUT.  497 

uratica),  usually  attacking  the  joints  of  the  lower  extremity, 
and  particularly  those  of  the  great  toe  (podagra)  ;  by  acute 
or  subacute  attacks  of  polyarthritis;  or  by  a  variety  of  irreg- 
ular manifestations.  While  the  view  that  gout  is  primarily 
a  disturbance  of  purin  metabolism  is  generally  accepted,  some 
authorities  consider  it  a  toxemia  of  hepatic  and  intestinal 
origin,  and  regard  the  uric  acid  deposits  as  merely  incidental. 
The  relation  of  the  uric  acid  to  the  overt  manifestations  of 
the  disease  is  obscure.  Most  theories  connect  it  in  some  way 
with  the  precipitation  of  monosodium  urate  in  the  joints  and 
elsewhere.  The  popular  idea  of  uric  acid  poisoning  is  based 
on  the  erroneous  assumption  that  uric  acid  is  toxic.  Many 
conditions  are  attributed  to  the  uric  acid  diathesis,  which  are 
identical  with  those  at  times  ascribed,  with  equal  lack  of  dis- 
crimination, to  neurasthenia  or  intestinal  autointoxication. 

The  uric  acid  diathesis  is  a  term  that  has  very  properly  fallen 
into  disrepute  and  has  long  formed  a  cloak  for  ignorance.  The 
condition  which  the  term  was  intended  to  designate  is  one  in 
which  the  patient  sufifers  from  one  or  more  of  the  various  and 
many  symptoms  met  with  in  arthritis  in  general,  including 
neuritis  and  headache. 

Gout  is  one  of  the  few  diseases  in  which  the  uric  acid 
metabolism  is  believed  to  play  a  causative  role,  and  in  general 
the  term  uric  acid  diathesis  is  a  misnomer. 

Typical  podagra  is  relatively  rare  except  in  England,  be- 
cause in  no  other  country  have  widespread  conditions  of 
leisure  and  luxury  existed  for  so  many  generations.  On  the 
other  hand,  the  statistics  of  Futcher^'*  indicate  that  among  the 
general  population,  exclusive  of  the  upper  classes,  gout  is 
almost  as  common  in  the  United  States  as  in  England.  In 
the  latter  country  there  is  undoubtedly  a  disposition  to  at- 
tribute too  many  complaints  to  a  gouty  origin,  and  in  this  coun- 
try we  have  fallen  into  the  same  error,  having  labeled  some 
cases  of  arthritis  and  rheumatism — particularly  in  those  past 
middle  age — as  subacute  or  chronic  gout.  The  tendency  at 
present  is  to  limit  the  term  rheumatism  to  the  acute  specific 
infection  (rheumatic  fever).  Some  of  the  cases  of  acute  poda- 
gra occasionally  seen  are  associated  with  renal  sclerosis  and 
a  history  of  alcoholism.  In  these  patients  there  is  usual! \-  no 
hereditary  element. 

32 


498       DISEASES    OF   METABOLISM    AND    NUTRITION. 

Of  heredity,  an  important  factor  in  England,  Roberts'*-^ 
says  that  "fully  three-fourths  of  the  cases  of  gout,  occurring 
among  the  easy  classes,  can  be  traced  back  distinctly  to 
a  gouty  ancestry."  In  many  instances,  however,  English 
authors  do  not  seem  to  be  very  critical  in  their  judgment  of 
what  constitutes  a  history  of  the  gout.  Thus  asthma,  sore 
throat  and  eczema  are  classified  as  gouty,  often  on  seemingly 
insufificient  grounds.  Patients,  moreover,  are  very  prone  to 
attribute  their  own  maladies  and  those  of  their  forbears  to 
this  aristocratic  disease.  It  may  be  safely  asserted  that  the 
hereditary  factor  is  relatively  unimportant  in  this  country. 

Gout  is  a  disease  of  middle  life — after  40 — and  is  much 
more  common  in  men  than  in  women.  The  incidence  of  gout 
in  middle-aged  men  is  accounted  for  by  their  special  liability 
to  overindulgence  in  rich  food  and  malt  liquors.  In  women 
the  menstrual  discharge  is  thought  by  many  to  have  a  pro- 
phylactic value.  All  authorities  agree  that  the  deleterious 
effect  of  alcoholic  beverages  is  not  in  proportion  to  their 
alcoholic  content.  Distilled  liquors  are  more  likely  to  lead  to 
cirrhosis  of  the  liver,  while  wines,  particularly  those  which 
have  been  fortified  or  refermented  (port,  sherry,  burgundy, 
champagne),  ales  and  porter  are  conducive  to  gout.  A  nitro- 
genous diet,  per  se,  provided  that  it  does  not  contain  an  excess 
of  purins,  is  not  now  considered  injurious  in  cases  of  pure  gout 
{i.e.,  without  renal  involvement). 

In  England  lead-workers  are  unusually  predisposed  to 
gout,  but  this  coincidence  is  not  common  in  this  country. 
Brewery  workers,  stewards,  butlers,  and  others  who  have  free 
access  to  rich  food  and  alcoholic  beverages  often  develop  this 
disease.  Exercise  may  serve  to  neutralize  bad  dietetic  habits, 
but  is  by  no  means  a  panacea.  In  persons  predisposed  to 
gout  some  exceptional  influence,  such  as  trauma  or  cold,  may 
induce  an  acute  or  subacute  manifestation ;  thus,  a  "gouty" 
arthritis  or  neuritis  may  seemingly  follow  overstrain  or  slight 
injury.  Emotional  causes  are  also  credited  with  a  similar 
effect.  Sir  William  Roberts  believed  that  a  course  of  treat- 
ment with  waters  containing  sodium  salts  was  very  likely  to 
induce  an  attack  of  acute  podagra.  Finally  we  must  empha- 
size the  association  of  gout  and  chronic  nephritis.  The  latter 
causes  a  retention  of  uric  acid  in  the  blood. 


GOUT.  499 

As  stated  in  the  definition,  gout  is  associated  with  the 
deposition  of  salts  of  uric  acid  in  the  joints  and  elsewhere. 
The  metatarsophalangeal  joints  of  the  great  toe  are  those 
most  often  attacked.  The  instep,  ankles,  knees,  hands,  and 
wrists  are  affected  approximately  in  the  order  indicated.  The 
elbows,  shoulders  and  hips  are  rarely  attacked,  and  the  artic- 
ulations of  the  jaw  and  the  sternoclavicular  joints  almost 
never.  Abarticular  deposits  are  described  in  the  following 
situations :  the  rim  of  the  ear,  the  tendons,  the  aponeuroses, 
the  skin  of  the  palms  and  soles,  the  eyelids,  nose,  vocal  cords, 
cranial  and  spinal  dura  and  pia  mater,  the  sclerotic  coat  of  the 
eye,  the  fibrous  sheaths  of  nerve-trunks,  the  aortic  valves. ^'^ 
The  nodules  on  the  helix  of  the  ear,  which  are  by  far  the  most 
common,  at  first  contain  a  whitish  fluid,  but  subsequently  are 
converted  into  minute,  solid,  whitish  nodules,  which  may  be 
readily  removed  for  examination.  Osier  warns  us  not  to  mis- 
take the  Darwinian  tubercle,  which  corresponds  to  the  primi- 
tive tip  of  the  ear,  for  a  gouty  tophus.  In  chronic  gout  the 
tophi  may  be  the  only  overt  manifestation  of  the  disease.  In 
certain  cases  of  so-called  deforming  gout,  there  are  irregular 
"chalky"  deposits  or  nodes  in  or  about  the  joints  of  the  hands 
and  elbows,  and  in  aggravated  examples  of  such  deformities 
the  hands  resemble  fantastic  roots  or  tubers. 

With  the  x-rsL-y  the  gouty  nodules  cast  a  very  faint 
shadow.  The  heads  of  the  phalanges  and  other  affected  bones 
show  characteristic  circular  areas  of  absorption  from  a  milli- 
meter to  a  centimeter  in  diameter,  which  are  surrounded  by 
dense  ring-like  borders.  Pathologically,  the  tophi  as  well  as 
the  areas  of  rarefaction  are  found  to  contain  crystals  of 
monosodium  urate.  In  joints  affected  by  gout  the  uratic 
deposit  is  found  close  to  the  surface  of  the  cartilage,  but 
separated  by  a  thin  endothelial  layer  from  the  joint-cavity. 
In  the  tendons  and  other  connective-tissue  structures  the 
uric  acid  salts  are  deposited  in  the  interstices,  and  sometimes 
may  be  dissolved  out  without  leaving  any  gross  alterations. 
Necrosis  and  other  pathologic  changes — whether  primary  or 
secondary  is  a  matter  of  dispute — are  frequently  seen  in  con- 
nection with  gouty  lesions. 

Uric  acid  is  the  product  of  the  destructive  metabolism 
(catabolism)   of  the  nucleins,  not  of  the  proteins  in  general. 


500       DISEASES    OF   METABOLISM    AND    NUTRITION. 

By  a  process  of  deamidization  and  oxidation  brought  about 
by  specific  ferments,  adenin  and  guanin  are  split  off  from 
nucleic  acid,  and  from  these,  in  turn,  hypoxanthin  and  xan- 
thin,  from  which  uric  acid  is  derived.  These  five  substances 
are  spoken  of  as  purin  bodies,  because  of  their  supposed  rela- 
tion to  a  hypothetic  substance  known  as  purin.  The  formulae 
follow:  purin  (C5H4N4)  ;  adenin  (C5H5N5),  6-aminopurin ; 
guanin  (C5H5N5O),  2-amino-  6-oxypurin ;  hypoxanthin  (C-,- 
H4N4O),  6-oxypurin;  xanthin  (C5H4N4O2),  2-6-dioxypurin ; 
uric  acid  (C5H4N4O3),  2-6-8-trioxypurin.  The  exogenous 
purins  are  those  derived  from  the  nuclein  of  ingested  foods ; 
the  endogenous,  from  the  nucleins  of  the  patient's  own  body 
cells.  The  excretion  of  the  former  can  be  readily  controlled 
by  dietetic  treatment,  while  the  excretion  of  the  latter  is 
peculiar  to  the  individual,  and  cannot  be  controlled  in  the 
same  way.  Foods  distinctly  harmful  on  account  of  their  high 
content  of  purins  are  those  rich  in  nucleins :  glandular  organs 
(liver,  sweetbreads,  kidneys),  broths  and  meat-soups.  Meats 
in  general,  including  fowl  and  fish,  and  leguminous  vegetables 
are  harmful  in  a  minor  degree.  Milk,  butter,  eggs,  cheese, 
most  cereals,  fruit,  nuts,  and  green  vegetables  are  nearly,  or 
quite,  purin-free. 

As  already  stated  (see  p.  451),  uric  acid  is  a  normal  con- 
stituent of  the  blood  (on  a  purin-free  diet  from  0.5  to  2.9 
mgs.  per  100  Gms.  of  blood).  Pratt"^'^  and  others  have  shown 
that  uric  acid  is  present  in  moderate  excess  (average  Z.7  mgs. 
per  100  Gms.  of  blood)  in  chronic  gout,  and  in  more  consider- 
able amounts  {e.g.,  5.7  mgs.)  at  the  beginning  of  an  acute 
attack.  Excess  of  uric  acid  in  the  blood  is  spoken  of  as  uric- 
emia.  Walker  HalH^  differentiates  :  (1)  temporary  or  dietetic 
uricemia  (after  food  rich  in  purins)  ;  (2)  functional  uricemia 
(in  leukemia  and  pneumonia)  ;  (3)  retention  uricemia  (in 
renal  disease  and  uremia)  ;  (4)  permanent  uricemia  (in  gout). 
He  states  that  in  gout  associated  with  contracted  kidney  as 
much  as  20  milligrams  of  uric  acid  per  100  mils  of  blood 
have  been  found. 

The  urine  of  chronic  gout  shows  no  constant  variation  in 
uric  acid  excretion,  though  most  investigators  have  found  a 
diminished  output.  In  an  acute  attack  uric  acid  is  diminished 
in  the  beginning  and  increased  as  the  attack  subsides.     With 


GOUT.  501 

this  there  is  a  parallel  change  in  the  excretion  of  phosphoric 
acid.  In  chronic  gout  it  is  common  to  find  the  urine  with  a 
low  specific  gravity,  a  faint  trace  of  albumin,  and  a  few  casts. 
In  an  acute  attack  there  are  the  high  color,  high  acidity,  and 
precipitation  of  urates  common  to  fevers.  Neither  the  blood 
nor  the  urine  of  gout  shows  any  constant  diminution  of  alka- 
linity or  increase  of  acidity,  in  spite  of  the  popular,  and  even 
professional  opinion  to  the  contrary. 

A  typical  acute  attack  of  the  gout  comes  on  with  little  or 
no  warning,  very  often  in  the  middle  of  the  night.  Occasion- 
ally prior  to  an  attack  the  patient  may  have  sufifered  from 
digestive  disturbances  or  vague  joint-pains.  The  aftected 
joint,  which  in  more  than  half  the  cases  is  that  of  the  great 
toe,  becomes  red,  swollen,  hot  and  exquisitely  tender.  These 
symptoms  may  be  so  intense  that  abscess  may  be  suspected ; 
indeed,  in  one  case  that  came  under  observation  a  phy- 
sician urged  "immediate  incision"  of  the  supposed  "felon"  (in 
this  instance  a  finger  was  affected).  The  swelling  persists 
from  a  few  days  to  a  week  or  more,  and  in  the  early  stages 
is  accompanied  by  moderate  fever  and  associated  symptoms: 
rigors,  sweating,  loss  of  appetite,  concentrated  scanty  urine, 
etc.  The  symptoms  frequently  remit  during  the  dav,  only  to 
recur  with  increased  severity  at  night.  In  addition  to  the 
original  focus,  other  joints  may  be  affected,  particularly  those 
of  the  tarsus  and  ankle  on  the  same  or  on  the  opposite  side ; 
less  often  the  joints  of  the  upper  extremities.  At  the  height 
of  the  swelling  the  tissues  surrounding  the  affected  joint  may 
pit  on  pressure.  This  and  the  subsequent  desquamation  are 
regarded  as  suggestive,  from  a  diagnostic  point  of  view.  A 
person  who  has  had  an  attack  of  gout  frequently  suff'ers 
subsequently  from  annual  or  semiannual  visitations  of  the 
malady.  This  tendency  to  recurrence,  although  not  a  con- 
stant factor,  is  characteristic.  Recurrences  may,  or  mav  not, 
be  prevented  by  careful  dietetic  treatment.  An  attack  such 
as  that  described  is  most  often  seen  in  the  hereditary  type, 
and  in  these  instances  there  may  be  little  or  no  evidence  of 
nephritis.  On  the  other  hand,  in  chronic  diffuse  nephritis  it 
is  not  unusual  to  see  quite  similar  manifestations,  not  rarely 
following  an  attack  of  uremia.  In  these  patients  retention 
uricemia  is  obviously   a  more  important  factor  than  in  the 


502       DISEASES    OF   METABOLISM    AND    NUTRITION. 

uncomplicated  disease.  A  third  variety  of  acute  or  subacute 
gout  is  the  polyarticular  form.  This  may  be  difficult  to  dif- 
ferentiate from  acute  articular  rheumatism.*  ^9  'phg  ^gg  Qf  ^j^g 
patient,  the  history,  the  laboratory  findings,  and,  most  im- 
portant of  all,  the  presence  of  tophi  will  point  to  the  diagnosis. 

Subjects  of  acute  gout  in  time  present  the  evidence  of  the 
chronic  affection :  tophi  in  the  ears,  about  the  smaller  joints 
and  elsewhere.  They  also  may  be  victims  of  recurrent  sore 
throat,  asthma,  and  other  conditions  to  which  gout  predis- 
poses. The  ultimate  prognosis  of  gout  depends  largely  upon 
the  complications,  and  in  particular  upon  the  condition  of  the 
kidneys  and  of  the  vascular  system. 

Chronic  gout  may  be  associated  with  the  acute  form  or 
pursue  its  course  without  typical  acute  attacks.  The  victims 
of  the  gouty  diathesis  are  traditionally  inclined  to  obesity ; 
they  are  florid  and  thin-skinned,  with  a  tendency  to  vascular 
hypertension.  The  high  blood-pressure  is  probably  due  to 
renal  fibrosis,  as  we  see  patients  with  distinct  gouty  tophi  and 
normal  urine  whose  blood-pressure  is  normal  or  subnormal. 
Gouty  patients  suffer  from  a  great  variety  of  affections, 
attributed  with  more»or  less  probability  to  the  underlying  vice 
of  metabolism.  When  such  symptoms  occupy  the  foreground 
we  speak  of  the  condition  as  irregular  gout.  The  following 
is  a  brief  systematic  enumeration  of  some  of  these  affections 
mentioned  by  authors,  but  in  many  cases  the  etiologic  link 
is  not  very  evident: 

Neuritis  and  migraine  are  common  in  gouty  subjects,  and 
are  relieved  by  measures  similar  to  those  useful  in  gout. 
Undoubtedly  other  toxemias  may  produce  similar  manifesta- 
tions. The  cases  of  "neuritis"  attributed  to  this  cause  have 
not  shown  pronounced  atrophy  or  complete  loss  of  reflexes. 
It  is  often  difficult  to  exclude  fibrositis.  Vertig-o,  irritability, 
mental  depression,  and  insomnia  are  common  functional  symp- 
toms. Apoplexy  is  the  result  of  the  accompanying  vascular 
sclerosis. 

Tachycardia,  precordial  oppression,  and  anginoid  pains 
are  common  in  this  disease,  and  may  be  related  to  a  hypo- 


*  Brugsch^o    describes    a    polyarticular    form    which    closely    simulates 
rheumatoid  arthritis. 


GOUT.  503 

thetic  toxemia.  High  blood-pressure,  sclerosis  of  the  arteries, 
myocarditis,  hypertrophy  and  dilatation  of  the  heart  are  the 
sequels  or  concomitants  of  the  complicating  nephritis,  rather 
than  of  the  uric  acid  diathesis  itself.  Phlebitis  is  described 
as  a  common  symptom. 

The  connection  of  gout  with  affections  such  as  laryngitis, 
bronchitis,  asthma,  pharyngitis  and  hyperchlorhydria  is  more 
problematic,  and  certainly  of  very  little  practical  importance 
in  American  practice.  The  association  of  chronic  nephritis 
with  gouty  deposits  in  the  joints  and  with  frank  gout  is 
indubitable.  It  is  more  likely  that  the  renal  insufficiency 
precipitates  the  gouty  attack  by  interference  with  elimination 
(retention  uricemia),  than  that  a  gouty  toxemia  initiates  the 
renal  mischief.  Fibrositis  or  myalgia  is  a  distinct  affection 
to  which  cold  and  trauma  seem  to  predispose.  It  may  fre- 
quently simulate  neuritis.  It  is  quite  possible  that  in  some 
cases  the  gouty  diathesis  may  be  a  predisposing  factor. 

Acute  articular  rheumatism,  .various  forms  of  infectious 
arthritis,  and  arthritis  deformans  of  several  types  are  to  be 
carefully  distinguished  from  gout.  We  should  suspect  gout 
as  a  possible  cause  in  any  case  of  acute  "rheumatism"  w^hich 
attacks  the  lower  extremities  predominantly,  and  is  unaccom- 
panied by  endocarditis.  The  suspicion  is  strengthened  if  the 
patient  be  no  longer  youthful,  and  salicylates  fail  to  have  their 
customary  happy  effect.  Arthritis  deformans,  on  the  othei 
hand,  is  more  likely  to  be  considered  gout  than  the  reverse. 
Persistence  of  the  symptoms,  the  spindle  form  of  the  joints, 
and  the  development  of  atrophy,  or  of  exostosis,  are  a  few 
of  the  signs  which  should  suggest  the  correct  diagnosis. 
Heberden's  nodes  are  never  to  be  considered  as  a  manifesta- 
tion of  gout,  although  a  gouty  person  may  present  them. 

Eczema  is  so  common  a  complication  of  gout  that  the  lat- 
ter must  be  admitted  as  one  of  its  causes.  In  this  disease  it 
occurs  most  frequently  about  the  face,  as  a  dry,  scaly  erup- 
tion. Psoriasis  and  other  skin  diseases  have  also  been  attrib- 
uted to  a  gouty  origin.  Schamberg  found  that  patients  with 
psoriasis  retained  nitrogen,  and  were  benefited  by  a  diet  poor 
in  nitrogen. 

Rarely  as  a  result  of  treatment,  or  spontaneously,  an  acute 
articular  gout  may  suddenly  disappear,  and  be  succeeded  by 


504       DISEASES    OF   METABOLISM    AND    NUTRITION. 

severe  cerebral,  cardiac,  or  gastrointestinal  symptoms — the 
so-called  retrocedent  gout.  Cold  applications  to  the  joints 
(probably  without  good  reason)  are  sometimes  credited  with 
this  dire  effect. 

TREATMENT. 

Certain  general  principles  apply  to  the  treatment  of  the 
gouty  diathesis,  independently  of  its  overt  manifestations, 
acute,  chronic  or  irregular.  Whatever  our  theories  as  to  the 
ultimate  cause  of  gout,  its  uniform  association  with  defective 
uric  acid  metabolism,  is  the  one  outstanding  fact  upon  which 
all  may  agree.  This  fundamental,  if  not  primary,  defect 
should,  therefore,  be  the  first  consideration  in  treatment.  If 
we  follow  the  analogy  of  diabetes  our  aim  should  be  to 
strengthen  the  impaired  functions  by  functional  rest.  There 
are  also  other  disturbances  of  metabolism,  and  of  the  various 
systems,  renal,  cardiovascular  and  digestive,  which  will  uni- 
formly require  investigation^  and  probably  therapeutic  atten- 
tion. Gouty  subjects  suffer  from  faulty  digestion,  unstable 
metabolism  and  imperfect  elimination.  Their  margin  of 
safety  is,  therefore,  limited  in  these  and  other  directions,  and 
they  must  be  subjected  to  corresponding  limitations.  In  all 
cases  individualization  is  most  important. 

The  condition  of  many  of  the  organs  and  functions  may 
be  arrived  at  by  special  functional  tests,  as  well  as  by  the 
ordinary  clinical  laboratory  methods,  A  careful  examination 
of  the  urine,  with  special  references  to  low  specific  gravity, 
traces  of  albumin,  and  casts  may  be  supplemented  by  estima- 
tion of  the  blood-pressure,  phenolsulphonephthalein  elimina- 
tion in  the  urine,  and  total  non-protein  nitrogen  of  the 
blood  (method  of  Folin).  If  facilities  for  nitrogen  estimates 
are  not  available,  the  urea  of  the  blood  may  be  determined  by 
the  urease  method.  In  this  way  a  good  idea  of  the  functional 
capacity  of  the  kidney  may  be  obtained.  Folin  has  devised  a 
method  for  the  quantitative  elimination  of  uric  acid  in  the 
Ijlood,  but  this  is  rather  too  complicated  for  clinical  purposes. 
Simpler  and  more  useful,  perhaps,  is  the  estimation  of  the 
uric  acid  elimination  in  the  twenty-four-hour  specimen  of 
urine,  first  on  a  purin-free  diet,  and  then  on  a  diet  rich  in 
purins.     The  normal  excretion  on  a  purin-free  diet  is  0.4  to 


GOUT.  505 

0.6  grams  (equivalent  to  0.11  to  0.17  Gms.  uric  acid  N), 
while  added,  purins  are  rapidly  eliminated.  In  the  gouty  the 
daily  excretion  may  be  diminished,  and  added  purins  are 
very  slowly  eliminated,  generally  requiring  more  than  two 
days.  It  is  also  well  to  test  the  patient's  tolerance  for  sugar 
as  described  under  "Diabetes" — by  the  administration  of 
100  grams  of  glucose.  The  gastric  and  intestinal  functions 
should  be  investigated  by  the  usual  test-meals,  and  by  the 
Schmidt  diet.  This  will  reveal  alterations  in  acidity,  faulty 
digestion  of  meats,  fats  and  starches,  etc. 

DIET. 

The  diet  should  be  arranged  to  meet  the  following  indica- 
tions:  (1)  Faulty  elimination  of  uric  acid  and  purins,  to  be 
met  by  a  diet  free,  or  nearly  free,  from  purins.  (2)  Im- 
paired nitrogenous  excretion,  depending  on  the  state  of 
the  kidney;  to  be  met  by  moderate  or  strict  limitation  of 
protein  generally.  (3)  Glycosuria,  usually  successfully  met 
by  restriction  of  sugars  alone.  (4)  Tendency  to  overnutri- 
t:on;  to  be  met  by  a  modified  obesity  diet.  (5)  Digestive 
disturbances,  hyperacidity,  flatulence  and  constipation ;  to  be 
met  by  restriction  of  starches,  administration  of  green  vege- 
tables and  fruits,  and  by  the  exclusion  of  indigestible  articles. 

The  following  table  shows  the  purin  content  of  the  prin- 
cipal foodstuffs : 

Purin  Base-content  of  Various  Articles  of  Diet  According  to  Hesse. 

(The  purin  bases  in  this  table  are  calculated  as  "uric  acid." 

Grams  of  uric  acid  in  100  grams.) 

Thymus    1.308  Sole    0.137 

Liver    0.372  Caviar    0.110 

Kidneys    0.320  Oysters    0.217 

Brain   0.233  String-beans    trace 

Beef    0.175—0.189  Carrots    0.007 

Mutton  0.189—0.191  Potatoes    0.019 

Veal    0.178—0.189  Asparagus    0.057 

Pork    0.181—0.185  Cabbage    0.078 

Chicken    0.186  Green   peas    0.079 

Venison    0.182  White  beans    0.098 

Squab    0.154  Pea  meal    0.108 

Trout    0.213  Wheat  meal    0.116 

Salmon    0.201  Rye  meal    0.096 

Pike    2.222  Milk  0.010 

Cod    0.131  Eggs    trace 

The  most  important  purin-free,  or  nearly  purin-free,  arti- 
cles of  diet  are :    milk,  butter,  cheese,  white  bread,  tapioca, 


506       DISEASES    OF    METABOLISM    AND    NUTRITION. 

rice  and  other  cereal  foods  in  which  the  outer  coating-  of  the 
grain  is  removed,  fruits,  nuts,  and  green  vegetables  (except 
asparagus,  cabbage  and  green  peas).  Except  in  very  rigid 
diets  root  vegetables  are  also  allowable,  particularly  carrots 
and  turnips.  Dried  beans,  peas  and  lentils  are  comparatively 
rich  in  purins.  Experiments  of  Luff  (/.c)  seem  to  show  that 
spinach,  Brussels  sprouts,  cabbage,  French  beans,  celery  and 
turnips  are  of  positive  benefit,  since  their  mineral  constituents 
tend  to  increase  the  solubility  of  sodium  biurate  in  vitro. 

In  an  acute  or  a  subacute  attack,  or  during  convalescence, 
a  diet  as  nearly  as  possible  purin-free  should  be  prescribed. 
In  the  febrile  period  this  may  consist  largely  of  milk,  but  sub- 
sequently any  articles  from  the  foregoing  list  may  be  selected. 
In  convalescence,  certain  meats  may  be  allowed  once  a  day. 

The  following  articles  should  be  avoided  by  the  gouty  r^^ 

Rich  meat  soups — ox-tail,  turtle,  mock-turtle,  kidney,  mul- 
ligatawny, hare,  giblet. 

Salmon,  mackerel,  eels,  lobsters,  crabs,  mussels,  salted 
fish,  smoked  fish,  preserved  fish,  tinned  fish.  Duck,  goose, 
pigeon,  high  game.    Meats  cooked  a  second  time. 

Hare,  venison,  pork,  lean  ham,  liver,  kidney ;  salted  or 
corned  meats,  pickled  meats,  preserved  and  potted  meats ; 
sausages ;  all  highly  seasoned  dishes  and  rich  sauces. 

Tomatoes,  beet-root,  cucumbers,  rhubarb,  mushrooms, 
truffles. 

Rich  pastry,  rich  sweets,  new  bread,  cakes,  nuts,  dried 
fruits,  ices,  ice-cream. 

In  chronic  or  irregular  gout,  or  in  the  intervals  between 
acute  attacks,  meat  or  fish  may  be  allowed  once  a  day,  but 
organs  unusually  rich  in  purins,  such  as  liver,  kidneys,  sweet- 
breads, and,  perhaps,  leguminous  vegetables,  should  be  for- 
bidden. Coffee,  tea  and  chocolate  should  be  used  in  great 
moderation,  or  not  at  all.  Coffee  prepared  with  hot  milk  in 
the  French  fashion  {cafe  mi  lait),  or  freshly  steeped  weak  tea, 
may  be  permitted  to  those  who  are  dependent  on  their  morn- 
ing beverage.  Caffein-free  coffee,  and  various  coff'ee  substi- 
tutes are  also  admissible.  Caffein  and  theobromin  are 
methyl  purins,  but  the  best  evidence  at  hand  indicates  that 
they  are  eliminated  unchanged,  and  do  not  give  rise  to  uric 
acid  as  do  the  purin  bases.     It  is  well,  however,  to  exclude 


GOUT.  507 

coffee  and  tea  "on  suspicion,"  particularly  as  their  omission 
may  be  justified  on  other  grounds. 

The  protein  need  not  be  unduly  restricted  in  gout;  the 
amount  allowed  is  to  be  regulated  in  proportion  to  the  func- 
tional capacity  of  the  kidneys.  In  the  ordinary  case  protein 
may  be  safely  reduced  to  75  grams  a  day,  or,  with  posi- 
tive evidences  of  renal  insufficiency,  to  50  grams  or  less. 
Sodium  chlorid  may  be  advantageously  limited  if  there  be 
any  tendency  to  edema.  As  already  stated,  Sir  William 
Roberts  believed  that  sodium  salts,  in  general,  were  deleter- 
ious in  gout,  and  might  cause  a  precipitation  of  sodium  urate. 
Broths,  meat-soups  and  gravies,  which  are  rich  in  nitrogenous 
waste  products,  should  be  avoided,  particularly  so  if  the  case 
be  complicated  by  nephritis. 

Fats  are  well  borne,  and  need  only  be  restricted  if  there 
is  a  tendency  to  obesity,  or  if  they  interfere  with  digestion. 
The  latter  contingency  is  only  likely  when  they  are  em- 
ployed in  conjunction  with  carbohydrates,  as  in  pastry,  fried 
foods,  and  as  fat  meats  and  fish.  The  fat  prevents  access  of 
the  digestive  juices,  and  interferes  indirectly  with  digestion. 
Occasionally  there  may  be  a  subicteric  hue  and  clay-colored 
stools,  which  may  show  free  fat  under  the  microscope.  In 
such  cases  fats  may  be  temporarily  restricted. 

Carbohydrates  are  often  a  cause  of  difficulty  in  gouty  per- 
sons, quite  aside  from  the  production  of  glycosuria.  Dyspep- 
sia is  a  common,  virtually  an  invariable,  accompaniment  of 
gout,  and  is  more  often  of  an  "amylaceous"  type.  With  the 
clinical  symptoms  (heartburn,  water-brash,  flatulence),  and 
the  laboratory  evidences  (increased  acidity,  poor  starch  diges- 
tion) of  hyperchlorhydria,  amylaceous  articles  should  be  cut 
down.  (In  aggravated  cases  of  "flatulent"  dyspepsia  the 
"Saulsbury"  diet,  consisting  solely  of  lean  beef  and  hot  water, 
is  occasionally  used.)  The  most  appropriate  forms  in  which 
they  may  be  allowed  are  dry  toast,  rusks,  zwieback,  a  mod- 
erate amount  of  thoroughly  cooked  cereal  (preferably  with- 
out husks),  baked  potatoes,  and  finely  divided  green  vege- 
tables. Acids  and  acid  fruits  should  be  tabooed ;  also  articles 
which  tend  to  flatulence,  such  as  baked  beans  and  boiled  cab- 
bage. Condiments,  salt  (in  excess),  pepper,  mustard  and 
other  spices,  meat-broths  and  soups,  rich  sauces  and  relishes 


508       DISEASES    OF   METABOLISM    AND   NUTRITION. 

should  be  restricted,  because  they  tend  to  stimulate  acidity. 
Olive  oil,  cream,  butter,  tender  meat,  fish,  or  fowl  are  usually 
easily  digested  in  the  stomach,  and  may  be  allowed,  in  spite 
of  the  gouty  constitution.  Boiled  meats  are  preferable  to 
roasted,  because  a  certain  amount  of  extractives  are  removed 
in  this  way.  In  constipation  fruits  and  fruit  juices,  green 
vegetables,  olive  oil,  and  the  coarser  breads  and  cereals  may 
be  employed,  if  not  contraindicated  by  any  of  the  above 
conditions.  The  treatment  of  glycosuria  is  considered  under 
"Diabetes"  (q.v.). 

In  gout  free  administration  of  water,  either  as  ordinary 
soft  potable  water,  distilled  water,  or  mineral  water  (Poland 
or  Evian),  is  advisable,  except  in  cases  of  cardiac  insuffi- 
ciency, or  in  renal  cases  associated  with  dropsy.  The  water 
is  preferably  taken  between  meals,  as  well  as  at  night  and 
before  breakfast.  In  some  cases  it  may  be  preferred  hot. 
"Soft  drinks"  are  not  to  be  recommended,  as  they  are  often 
sweet,  and  upset  the  digestion.  In  general,  there  is  no  objec- 
tion to  lemonade,  weak  tea,  cider,  and  nutritious  beverages 
such  as  milk  and  plain  buttermilk.  Alcohol  should  be  for- 
bidden. The  harmfulness  of  alcoholic  beverages,  as  already 
pointed  out,  does  not  appear  to  be  connected  with  their  abso- 
lute alcoholic  content,  or  with  their  acidity.  Malt  liquors, 
port  and  sweet  wines  are  to  be  unreservedly  forbidden.  In 
exceptional  cases,  as  in  the  aged  and  infirm,  or  in  those  long 
addicted  to  the  use  of  alcohol,  claret  or  well-diluted  whisky 
or  gin  is  permissible. 

HYGIENIC   TREATMENT. 

On  account  of  their  defective  assimilation  and  elimination, 
the  subjects  of  the  gouty  diathesis  are  more  dependent  on 
exercise,  baths,  climate,  and  similar  aids  to  health  than 
normal  individuals.  Moderation  in  food  and  drink  indepen- 
dently of  any  special  restrictions,  regular  meals,  careful 
chewing,  a  plentiful  supply  of  pure  water,  and  attention  to 
regularity  of  the  bowels  are  essential. 

Outdoor  exercise  is  almost  always  advisable,  but  its  char- 
acter will  depend  upon  inherent  factors  such  as  the  patient's 
previous  habits  of  life,  the  condition  of  the  heart,  and  degree 
pf  obesity.    The  same  remarks  apply  here  as  in  obesity;  for 


GOUT.  509 

the  middle-aged,  golf  is  the  most  suitable  exercise,  but  its 
beneficial  effects  are  too  often  neutralized  by  indulgence 
in  rich  food  and  alcohol.  Walking  is  the  most  universally 
available  recreation,  particularly  valuable  in  cardiac  cases. 
Motoring  i§,  for  obvious  reasons,  probably  the  worst  possible 
recreation  for  an  able-bodied  gouty  individual.  Sedentary 
occupations  and  those  involving  exposure  to  lead  or  inviting 
to  the  use  of  malted  beverages  are  deleterious.  In  the  case 
of  lead-workers  a  change  of  occupation  should  be  arranged  ; 
for  those  following  other  occupations  provision  of  hours  for 
exercise  and  revision  of  the  habits  of  eating  and  drinking  will 
be  sufficient. 

Climatic  treatment,  except  in  association  with  the  use  of 
mineral  waters,  does  not  occupy  a  large  place  in  the  treatment 
of  gout.  A  cool,  bracing  climate,  favorable  to  outdoor  exer- 
cise, is  preferable  for  a  majority  of  persons.  In  foreign  coun- 
tries the  treatment  at  various  watering  places  has  been  highly 
developed,  and  through  a  combination  of  factors — regular 
hours,  graduated  exercise,  carefully  supervised  diet,  free  con- 
sumption of  water,  pleasant  surroundings  and  favorable  cli- 
mate— excellent  results  are  obtained.  This  is  especially  true 
of  persons  who,  through  choice  or  compulsion,  have  led  a 
life  of  inactivity  and  high  living  through  the  greater  part  of 
many  years.  The  mineral  constituents  of  the  various  springs 
differ  widely,  and  we  must  attribute  their  direct  influence  on 
uric  acid  metabolism  to  their  quantity,  rather  than  their 
quality.  The  waters  most  celebrated  for  this  purpose  are 
those  which  contain  the  least  mineral  constituents.  Many 
of  the  waters  are  hot,  and  this  may  add  to  their  local  and 
(general  effects.  At  all  the  spas  elaborate  provision  is  made 
for  baths,  douches,  massage,  etc.  The  special  value  of  lithium 
waters  has  long  since  been  discounted.  Other  mineral  springs 
contain  substances  which  are  useful  in  the  treatment  of  vari- 
ous concomitant  manifestations  and  complications  of  gout. 
As  stated,  their  direct  eff'ect  may  be  harmful,  because  in  most 
of  them  there  is  a  predominance  of  sodium  salts.  The  waters 
of  Vichy  are  rich  in  sodium  bicarbonate,  and  are  especially 
indicated  in  cases  with  hyperacidity.  The  Vichy  douche 
massage  is  a  celebrated  method  of  local  treatment.  The 
waters  of  Carlsbad  and  Marienbad  owe  their  virtue  to  a  com- 


510       DISEASES    OF    METABOLISM    AND    NUTRITION. 

bination  of  sodium  chlorid,  sodium  bicarbonate  and  sodium 
sulphate.  They  are  supposed  to  be  especially  useful  in  the 
congestion  of  the  liver,  cholelithiasis  and  constipation.  An- 
other class  of  mineral  springs,  much  resorted  to  by  the  obese 
and  the  gouty,  and  especially  indicated  in  catarrhal  conditions 
of  the  stomach  and  intestines,  is  characterized  by  their  high 
sodium  chlorid  content.  The  best  known  of  these  springs  are 
Homburg,  Wiesbaden,  Kissingen  and  Baden-Baden.  Various 
sulphur  springs,  such  as  Aix-les-Bains,  are  recommended  for  their 
local  effects  upon  the  joints,  and  particularly  upon  cutaneous 
manifestations.  In  this  country  waters  resembling  those  men- 
tioned are  to  be  found  at  Poland  Springs  (very  slightly  min- 
eralized), Saratoga  Spring's,  Bedford  Springs,  Hot  Springs  of 
Virginia,  White  Sulphur  Springs  and  elsewhere.  At  most  of 
these  resorts  excellent  accommodations  are  afforded,  and  at 
many  of  them  competent  physicians  are  available.  Elaborate 
provisions  are  also  made  for  baths,  massage,  local  treatment 
and  exercise.  The  discipline,  however,  is  not  so  good  as  at  the 
German  spas.  Most  of  the  visitors  are  bent  on  pleasure,  and 
it  is  difficult  for  patients  to  observe  a  strict  regime.  Many  en- 
thusiasts for  this  form  of  treatment  bolster  their  faith  with 
certain  chemical  discoveries.  Thus  they  claim  a  special  efifi- 
cacy  for  minute  amounts  of  mineral  salts,  on  account  of  their 
high  ionization.  Special  therapeutic  efficacy  is  also  ascribed 
to  the  radium  emanations  given  off  by  some  mineral  waters 
when  freshly  drawn.  The  accessory  modes  of  treatment  pro- 
vided at  the  various  resorts  are  now  equally  available  in  all 
our  large  cities,  and  a  physician  may  have  his  hydrotherapeutic 
prescriptions  carried  out,  just  as  in  the  case  of  drugs.  Most 
physicians,  however,  are  so  unfamiliar  with  the  general  pro- 
cedures that  they  are  inclined  to  leave  the  execution  of  details 
to  lay  hands.  With  greater  experience  this  fault  will  doubt- 
less be  corrected. 

The  electric-light  cabinet  bath  is  the  most  generally  useful 
apparatus  for  promoting  elimination.  The  operators  claim 
that  there  is  some  virtue  in  the  light  itself,  but  this  seems 
improbable.  Its  chief  superiority  consists  in  the  readiness 
with  which  the  heat  can  be  controlled.  The  portable  hot-air 
bath  will  serve  equally  well  in  private  practice.  When  a 
gentle  perspiration  has  been  established,  the  patient  is  given 


GOUT.  511 

a  lukewarm  or  cold  bath.  In  the  young  and  vig-orous,  with- 
out marked  elevation  of  blood-pressure  or  cardiac  weakness, 
a  cold  shower  or  plunge  is  employed.  Additional  stimulation 
may  be  given  by  the  Scotch  douche,  which  consists  of  alter- 
nating jets  of  hot  and  cold  water  under  high  pressure.  For 
the  less  vigorous  a  warm  rain  or  tub  bath,  followed  by 
gentle  massage,  is  safer.  Sometimes  alternating  hot  and  cold 
douches,  combined  with  massage,  are  used  on  individual 
joints. 

MEDICINAL  TREATMENT. 

A  large  number  of  drugs  have  been  vaunted  for  their 
alleged  specific  effects  on  uric  acid  metabolism,  some  because 
they  were  supposed  to  promote  solution  of  the  deposits,  others 
for  their  effect  on  elimination.  Still  others  have  been  pre- 
scribed to  alter  the  reaction  of  the  urine,  to  control  pain,  and 
to  combat  various  individual  symptoms. 

Colchicum  [tincture  of  colchicum-seed,  30  minims  (2  mils), 
and  colchicum,  %2o  grain  (0.5  mg.)],  has  long  enjoyed  a  high 
reputation  for  its  effect  on  the  pain  and  inflammation  in  acute 
gout.  It  has  no  effect  on  uric  acid  excretion,  and  some 
authors  go  so  far  as  to  attribute  its  favorable  action  solely 
to  its  purgative  qualities.  Colchicum  is  of  little  value  in 
chronic  gout. 

Salicylates  are  less  effectual  than  colchicum  in  controlling 
the  pain  of  gout,  but  they  increase  the  excretion  of  uric  acid 
to  a  marked  degree.  They  are  useful  in  subacute  and  chronic 
gout,  and  in  irregular  gout. 

Atophan-'^-  (phenylquinolin-carbonic  acid)  and  related 
compounds  (isatophan,  novatophan,  paratophan)  have  a  re- 
markable effect  on  the  excretion  of  endogenous  and  exogen- 
ous uric  acid.  Atophan  probably  promotes  the  formation 
(mobilization)  as  well  as  the  excretion  of  uric  acid.  Brugsch 
(/.  c.)  advises  that  it  be  given  for  two  days,  7^  grains  (0.5 
Gm.)  four  times  a  day,  to  15  grains  (1  Gm.)  three  times  a 
day,  and  then  be  suspended  for  a  week,  two  weeks,  or  a 
month.  It  should  not  be  used  in  acute  gout  until  the  attack 
is  subsiding.  Its  chief  use  is  in  the  treatment  of  chronic  gout, 
and  as  a  prophylactic  against  recurring  acute  attacks. 

Alkalies  and  alkaline  salts  (potassium,  lithium,  calcium 
and  sodium  carbonates,  or  bicarbonates,  and  citrates)   enjoy 


512       DISEASES    OF   METABOLISM    AND    NUTRITION. 

a  certain  reputation,  given  either  independently  or  as  adju- 
vants to  the  above  remedies.  The  administration  of  these 
substances  should  be  suspended  when  the  urine  becomes 
amphoteric  or  alkaline.  Potassium  is  the  base  usually  pre- 
ferred, while  sodium  has  been  considered  injurious.  Lithium 
has  no  particular  virtue  in  gout.  lodids  are  of  some  value 
in  chronic  "gouty"  and  "rheumatic"  conditions,  although  their 
action  is  not  clearly  understood. 

Piperazin,  lycetol,  lysidin,  quinic  acid,  sidonal,  citarin, 
urosin  and  similar  preparations  have  been  recommended  from 
time  to  time  because  of  their  supposed  power  of  dissolving  or 
increasing  the  solubility  of  uric  acid,  and  thus  hastening  its 
elimination.  Piperazin  was  used  very  extensively  at  one  time, 
but  neither  this  drug  nor  its  successors  have  found  any 
permanent  place  in  practical  medicine.  Piperazin,  like  lith- 
ium, dissolves  uric  acid  in  the  test-tube,  but  is  of  little  or  no 
value  in  the  body. 

TREATMENT  OF  THE  ACUTE  ATTACK. 

The  patient  with  an  acute  attack  of  gout,  associated  with 
fever,  should  be  confined  to  bed.  Usually  on  account  of  the 
painfulness  of  the  afifected  joint  or  joints,  he  will  have  no 
desire  to  leave  it.  The  temperature  should  be  taken  at  least 
three  times  a  day,  and  a  liquid,  preferably  a  milk  diet,  pre- 
scribed. Broths  are  not  advisable.  Water  should  be  given 
freely,  either  plain  or  in  the  form  of  the  "Imperial  Drink,"* 
The  affected  joints  should  be  protected  from  pressure  by*a 
cradle  or  splint.  In  the  case  of  the  foot  a  large  pad  should 
be  placed  beneath  the  tendo  achillis  to  prevent  pressure  upon 
the  heel.  The  joints  may  be  wrapped  in  raw  cotton,  or  may 
be  surrounded  with  gauze,  which  has  been  soaked  with  a 
saturated  solution  of  sulphate  of  magnesia.  Many  patients, 
however,  prefer  the  old-fashioned,  though  "unscientific"  lead- 
water  and  laudanum,  tr.  opii,  2  fluidounces  (60  mils)  ;  liq. 
plumbi  subacetatis,  1  fluidounce  (30  mils)  ;  aquae  q.  s.,  16 
fluidounces  (500  mils),  applied  on  lint  and  covered  with  oiled 


*  Imperial  Drink:  1  to  2  teaspoonfuls  of  cream  of  tartar,  dissolved  in 
hot  water  or  barley-water,  to  be  flavored  with  lemon-peel  and  slightly 
sweetened.    Drink  freely  when  cool. 


GOUT.  513 

silk  or  waxed  paper.  In  general,  warm  applications  are'  pre- 
ferable to  cold.  The  patient's  bowels  should  be  opened  by  a 
dose  of  calomel,  2  to  4  grains  (0.13  to  0.26  Gm.),  followed  up 
by  sulphate  of  magnesia  the  following  morning".  If  desired, 
the  time-honored  massa  hydrargyri  ("blue  pill")  may  be  used 
instead  of  calomel.  Subsequently  the  bowels  should  be  freely 
opened  from  time  to  time  by  saline  laxatives.  Potassium 
bicarbonate  or  potassium  citrate  in  15-  or  30-  grain  (1  or  2 
Gms.)  doses  should  be  given  every  three  hours,  freely  diluted 
with  water,  in  order  to  promote  elimination.  If  the  urine 
becomes  alkaline,  the  dose  should  be  reduced.  Colchicum  in 
the  form  of  the  tincture  of  colchicum-seed  may  be  given  at 
similar  intervals  in  15-minim  (1  mil)  doses;  the  dose  should 
be  gradually  reduced  after  an  effect  is  obtained. 

If  colchicum  causes  vomiting  or  diarrhea,  or  does  not 
relieve  the  pain,  some  preparation  of  salicylic  acid  may  be 
employed,  as  in  the  treatment  of  rheumatism.  Aspirin  and 
salicin  are  sometimes  to  be  preferred  to  sodium  salicylate 
because  they  are  far  less  irritating  to  the  stomach.  The  dose 
of  salicin  is  double  that  of  sodium  salicylate. 

Atophan,  7^  grains  (0.5  Gm.),  four  times  a  day,  may  be 
used  before  the  attack,  if  premonitory  symptoms  are  present, 
or  after  the  acute  stage  has  passed.  It  should  be  continued 
for  two  or  three  days,  stopped,  and  then  repeated  at  weekly 
intervals. 

A/ter  a  few  days  the  fever  usually  falls,  but  the  arthritic 
symptoms  may  persist  for  a  week  or  two.  With  the  subsi- 
dence of  the  acute  symptoms,  the  diet  may  be  increased  bv 
the  addition  at  first  of  toast  and  cereals,  and  later  of  other 
articles  given  in  the  purin-free  diet  (v.  s.).  With  complete 
convalescence,  a  diet  with  a  moderate  amount  of  purin  and 
protein  food  is  permissible.  So  long  as  the  joints  remain 
tender,  local  applications  will  suffice.  Subsequentl)'  gentle 
massage,  passive  movements,  and  douching  with  alternate 
hot  and  cold  Avater  will  be  useful  to  restore  function.  Bier's 
treatment  by  passive  hyperemia  may  be  employed  wath  good 
effect  in  some  cases.  Raking  (superheated  air)  is  used  to 
favor  absorption  in  cases  in  which  there  is  persistent  thick- 
ening. Potassium  iodid  may  also  be  prescribed  for  the  same 
purpose,  in  doses  of  5  to  10  grains  (0.3  to  0.6  Gm.),  three  or 

33 


514       DISEASES    OF    METABOLISM    AND    NUTRITION. 

four  times  a  day.  Between  the  attacks,  prophylactic  treat- 
ment should  be  directed  against  the  underlying  gouty  diathesis. 
The  treatment  of  chronic  gout  and  the  gouty  diathesis  will 
consist  almost  wholly  in  the  proper  readjustment  of  the 
patient's  habits  of  life.  A  careful  study  should  be  made  of 
his  previous  diet,  habits  as  to  alcoholic  beverages,  amount 
and  character  of  exercise,  and  like  details.  Special  attention 
should  also  be  given  to  the  digestive,  circulatory  and  renal 
functions.  Thus,  a  vegetarian  diet,  while  theoretically  pre- 
ferable to  spare  the  uric  acid  metabolism,  may  unduly  overtax 
the  digestion.  The  general  principles  which  should  regulate 
the  diet  and  exercise  have  already  been  explained.  In  these 
cases  an  occasional  period  of  treatment  at  some  watering- 
place  will  prove  useful.  Gouty  deposits,  either  about  the 
joints  or  elsewhere,  will  be  but  slightly  influenced  by  local  or 
general  treatment,  but  local  massage,  douching,  packing,  pas- 
sive hyperemia,  and  hot-air  treatment  will  be  useful  to  im- 
prove the  functions  of  the  joints,  just  as  in  the  convalescent 
stage  of  the  acute  cases.  The  thorough  elimination  brought 
about  by  the  free  consumption  of  water  and  by  free  sweating 
is  also  useful  for  the  renal  complications,  and  the  various 
abarticular  manifestations  such  as  neuritis. 

TREATMENT    OF    IRREGULAR    GOUT   AND 
COMPLICATIONS. 

It  would  serve  no  useful  purpose  to  describe  the  treatment 
of  all  the  afl^ections  (many  of  which  have  already  been  enu- 
merated) supposed  to  have  a  gouty  basis.  Where  there  is 
good  reason  to  suspect  such  an  underlying  factor,  mercurials 
and  alkaline  diuretics  should  be  prescribed  as  an  aid  to  elimi- 
nation, and  the  usual  dietetic  restrictions  should  be  instituted. 
Potassium  iodid  and  guaiac  resin,  5  grains  (0.3  Gm.),  in 
cachets  or  konseals,  are  valuable  in  many  of  these  abarticular 
manifestations.  In  gouty  sore  throat  Mackenzie  was  wont  to 
recommend  guaiac  lozenges,  2  grains  (0.13  Gm.).  Eczema 
developing  on  a  gouty  basis  should  be  treated  by  general 
measures,  and  by  local  applications.  For  the  dry  form  a  use- 
ful application  is  the  following:  salicylic  acid,  10  to  20  grains 
(0.6  to  1.2  Gms.)  ;  zinc  oxid  and  starch,  each  2  drams  (8 
Gms.)  ;  petrolatum,  >^  ounce  (16  Gms.). 


DIABETES    MELLITUS.  515 

DIABETES    MELLITUS. 

Diabetes  is  a  constitutional  disease  characterized  by  per- 
sistent disturbances  of  carbohydrate,  and,  to  a  less  extent,  of 
protein  and  fat  metabolism.  It  is  probably  dependent  upon 
pathologic  changes  in  the  pancreas.  The  typic  clinical  fea- 
tures are :  hyperglycemia,  glycosuria,  polydipsia,  polyuria, 
emaciation,  acidosis  and  coma.  According  to  the  most  recent 
view,^^  diabetes  is  the  expression  of  a  weakened  function,  a 
defect  which,  under  proper  treatment,  is  not  essentially  pro- 
gressive. Glycosuria  is  a  symptom  which  may  occasionally 
be  due  to  other  causes  than  diabetes,  but  it  is  a  safe  clinical 
rule  (Joslin)  to  consider  it  such  until  proved  otherwise.  Ali- 
mentary glycosuria  ("glycosuria  e  saccharo")  is  due  to  the 
ingestion  of  an  excess  of  sugar  {e.g.,  100  to  200  grams  of 
glucose  on  a  fasting  stomach),  which  cannot  be  "warehoused" 
with  sufftcient  rapidity  to  prevent  hyperglycemia.  Renal 
diabetes  is  a  condition  of  increased  permeability*  of  the  kid- 
ney, in  which  the  excretory  cells  of  that  organ  fail  to  hold 
back  sugar  even  when  its  concentration  in  the  blood  is  nor- 
mal or  subnormal.  In  true  diabetes  sugar  is  eliminated  when 
starch  is  the  only  carbohydrate  ing"ested  ("glycosuria  ex 
amyli"),  or  even  when  the  diet  is  carbohydrate-free.  Occa- 
sionally other  sugars  than  glucose  may  appear  in  the  urine, 
e.g.,  pentose  and  lactose.  The  last  mentioned  may  be  present 
during  lactation,  and  has  no  relation  to  diabetes. 

Statistics  seem  to  show  conclusively  that  diabetes,  in  the 
last  few  decades,  has  rapidly  increased  in  frequency  in  all 
highly  civilized  urban  communities.  The  explanation,  aside 
from  greater  accuracy  in  diagnosis,  is  not  altogether  apparent. 
Two  factors  may  be  important :  the  vastly  increased  con- 
sumption of  sugar,  and  the  intensity  of  the  modern  pursuit 
of  business  and  pleasure.  The  former  tends  to  overtax  the 
mechanism  for  carbohydrate  utilization ;  the  latter  may  induce 
functional  disturbances  through  the  agency  of  the  nervous 
system.  Diabetes  occurs  at  all  ages,  but  is  more  common  in 
middle  life,  between  the  ages  of  40  and  60.     Males  are  more 


*  This  condition  may  lie  temporarily  induced  in  man  or  animals  by  the 
administration  of  phloridzin  ;  hence  "phloridzin  diabetes." 


516       DISEASES   OF   METABOLISM   AND   NUTRITION. 

often  attacked  than  females.  Not  rarely  both  husband  and 
wife  are  affected,  which,  as  in  obesity,  suggests  the  effect  of 
dietetic  habits.  The  relation  of  diabetes  to  pulmonary  tuber- 
culosis is  probably  accidental :  their  occasional  coincidence  is 
not  surprising  if  we  consider  the  frequency  of  the  latter  dis- 
ease. Toxic  and  infectious  changes  in  the  islands  of  Lan- 
gerhans  are  believed  to  be  important  by  von  Noorden,  who 
found  a  history  of  tonsillitis  in  15  per  cent,  of  his  cases.^'* 
Gout,  obesity,*  neuroses  and  psychoses,  whether  in  the 
patient's  own  history  or  in  that  of  his  antecedents,  may  have 
a  more  direct  connection.  Occupations  involving  a  sedentary 
life  or  mental  strain  and  worry  predispose  to  this  disease.  At 
times  more  obvious  nervous  insults — emotional  shock,  trauma, 
brain  injuries,  and  the  growth  of  brain  tumorsf — may  bring 
about  glycosuria.  The  undue  frequency  of  diabetes  among 
the  Jews  is  not  readily  explained,  but  may  be  attributed  to  a 
combination  of  several  of  the  above  causes :  heredity,  nervous 
temperament,  worry,  diet  and  physical  inactivity. 

The  generally  accepted  view  of  the  pathogenesis  of  dia- 
betes attributes  the  disturbance  of  carbohydrate  metabolism 
to  a  deficiency  in  the  internal  secretion  of  the  pancreas,  which, 
in  turn,  has  its  basis  in  a  peculiar  degeneration  of  the  cells  of 
the  islands  of  Langerhans  (Opie,  Allen  and  others).  In  the 
vast  majority  of  cases  enough  functionating  pancreatic  tissue 
is  left  to  afford  the  necessary  minimal  tolerance  for  carbohy- 
drate, provided  that  the  diet  is  properly  adjusted  to  the  weak- 
ened function.  The  nervous  system  has  a  profound  influence 
upon  carbohydrate  metabolism,  but  doubtless  acts  through 
the  agency  of  the  pancreas.  Many  authorities  believe  that  the 
sugar  metabolism  is  regulated  by  a  nice  correlation  between 
the  sympathetic,  the  endocrine  glands  and  the  pancreas. 
Thus,  nervous  stimuli  passing  from  the  medulla  by  way  of 
the  sympathetic  induce  secretion  of  the  adrenals  and  related 
structures.  These  internal  secretions,  in  turn,  stimulate  the 
liver  (the  principal  sugar  "warehouse")  to  produce  (or  re- 
lease)  sugar.     The  internal  secretion  of  the  pancreas,  on  the 


*  Fifteen  per  cent,  of  the  cases  of  alimentary  obesity  develop  diabetes. 
(Kisch.) 

t  A  diabetic  patient  under  observation  at  the  Philadelphia  General  Hos- 
pital had  a  stroke  at  the  age  of  40  (cerebral  syphilis). 


DIABETES    MELLITUS.  517 

Other  hand,  inhibits  the  liver,  but  in  its  turn  is  controlled  by 
the  internal  secretions  of  the  thyroid,  hypophysis,  etc.  Thus, 
increased  secretion  of  the  thyroid,  as  in  hyperthyroidism, 
tends  to  lessen  the  inhibitory  action  of  the  pancreas,  and  may 
cause  glycosuria.  This  interesting-  and  complicated  hypo- 
thesis is  of  more  interest  in  the  diagnosis  of  obscure  lesions 
of  the  ductless  glands  than  in  the  diagnosis  and  treatment  of 
diabetes.     For  practical  purposes  it  may  be  disregarded. 

The  most  frequent  pathologic  lesion  in  diabetes  consists 
of  a  vacuolation,  and  eventually  an  atrophy  of  the  islands  of 
Langerhans,  and,  in  particular,  of  certain  so-called  "beta" 
cells.  Extensive  disease  of  the  pancreas  (pancreatitis,  can- 
cer) may  exist  without  diabetes  if  the  "islands"  are  spared. 
Other  pathologic  lesions  frequently  found  in  association  with 
diabetes  are :  general  arteriosclerosis  (important  in  the  etiol- 
ogy of  gangrene),  pulmonary  tuberculosis,  cirrhosis  of  the 
liver,  chronic  diffuse  nephritis,  and  tumors  or  other  lesions 
of  the  brain. 

The  ordinary  sugars  (disaccharids)  and  starches  (polysac- 
charids)  of  the  diet  in  the  process  of  digestion  are  converted 
into  monosaccharids  (principally  glucose),  and  absorbed  as 
such.  The  glucose  is  carried  in  the  portal  blood  to  the  liver, 
and  subsequently  through  the  general  circulation  to  the  mus- 
cles, and  is  stored  in  these  localities  as  glycogen.  Under  nor- 
mal conditions  the  amount  of  glucose  in  the  blood  never 
exceeds  0.14  per  cent,  (usually  0.1  per  cent.),  and  only  traces 
— too  small  to  be  detected  by  ordinary  clinical  tests — are 
excreted  in  the  urine.  However,  if  very  large  amounts  of 
sugar  are  ingested,  e.g.,  more  than  100  grams  of  glucose, 
the  sugar  content  of  the  blood  may  rise  slightly,  and  the  kid- 
neys may  allow  sugar  to  escape,  even  in  normal  persons. 
Starch,  being  slowly  absorbed,  is  always  safely  "stored"  by 
the  normal  individual.  After  the  glycogen  has  been  deposited, 
it  is  held  in  reserve,  and  released  in  small  amount  as  required 
for  the  production  of  heat  and  energy.  In  diabetes  glucose 
is  either  not  stored  or  is  mobilized  in  excessive  amounts.  In 
mild  cases  a  portion  may  be  utilized  ("burnt")  ;  in  more 
severe  cases  all,  or  nearly  all,  is  lost  in  the  urine,  and  yields 
no  heat  or  energy  to  the  organism.  (The  loss  of  energy  from 
this  cause  is  often  very  great.    Thus,  a  very  severe  case  may 


518        DISEASES    OF   METABOLISM    AND    NUTRITION. 

eliminate  as  much  as  12.5  liters  (quarts)  of  urine  containing 
750  grams  (6  per  cent.)  of  glucose.  This  corresponds  to 
3000  calories,  sufficient  for  the  daily  maintenance  of  an  adult 
male  of  average  weight.)  In  either  case  the  sugar  content  of 
the  blood  is  increased  (hyperglycemia),  ranging  from  0.14  per 
cent.,  the  extreme  upper  limit  of  the  normal,  to  0.5  per  cent, 
or  more.  As  a  result  the  kidney  is  unable  to  hold  the  sugar 
back,  and  glycosuria  ensues.  In  the  mildest  forms  of  diabetes 
elimination  of  sugars  from  the  diet  may  suffice  to  banish  gly- 
cosuria, but  ordinarily  restriction  of  starches  is  also  essential. 
In  severe  cases  the  proscription  of  carbohydrates  is  insuffi- 
cient, and  protein  must  also  be  limited,  since  sugar  may  be 
derived  from  protein,  and  possibly  even  from  fat.  Different 
proteins  are  capable  of  yielding  varying  amounts  of  glucose 
(100  grams  of  isolated  proteins  may  yield  from  48  to  80  per 
cent,  of  sugar,  according  to  Janney^^)^  depending  upon  the 
amino-acids  which  they  contain.  When  protein  is  being  con- 
verted into  sugar,  and  excreted  as  such,  the  proportion  of 
glucose  (dextrose)  to  total  nitrogen  in  the  urine  rises.  This 
is  known  as  the  D :  N  ratio.  When  all  available  glucose  is 
being  wasted,  as  in  severe  diabetes  during  fasting,  this  may 
be  as  high  as  3.65  to  1  (Lusk,*)  or  3.65  to  6.25,  since  1 
gram  of  N  is  equivalent  to  6.25  grams  of  protein.  In 
diabetes  the  respiratory  quotient  (see  p.  457)  is  often  low, 
because  protein  is  being  burned  instead  of  carbohydrate.  In 
severe  cases  abnormalities  in  the  metabolism  of  fats  are 
also  observed.  If  carbohydrates  are  not  being  burned,  the 
economy,  for  some  reason  not  altogether  clear,  is  unable 
completely  to  oxidize  fats,  and  intermediary  products  of  fat 
metabolism  appear  in  the  blood  and  urine. f  Beta-oxybutyric 
acid  is  the  primary  substance  formed,  and  from  it  the  diacetic 
acid  and  acetone  of  the  urine  are  derived.  When  the  accumu- 
lation of  these  substances  in  the  body  is  large  we  have  the 
condition  known  as  acid  intoxication,  which  is  manifested  by 
typic  clinical  symptoms,  and  by  various  laboratory  findings. 
The  latter  comprise  diminution  of  the  carbon  dioxid  tension 
of  the  alveolar  air"'"  and  of  the  venous  blood,'^^  increase  of 


*3.40  to  1   (Janney). 

t  The  expression  "fats  burn  in  the  fire  of  the  carbohydrates"  (Naunyn) 
is  a  vivid  though  not  very  iHuniinating  .statement  of  this  fact. 


DIABETES    MELLITUS.  519 

the  ammonia  excretion  in  the  urine,  and  excessive  excretion 
of  beta-oxybutyric  acid  and  its  derivatives  in  the  urine. 
These  estimations  either  require  special  apparatus  or  demand 
some  technical  skill.  On  the  other  hand,  the  simple  qualita- 
tive tests  for  diacetic  acid  (ferric  chlorid)  and  acetone  in  the 
urine  are  simple  in  the  extreme.  Allen  finds  that  the  latter 
test  is  easily  applied  to  the  blood-serum,  and  is  valuable  in 
the  prompt  diagnosis  of  acidosis.  According-  to  Henderson, -"^^ 
a  practical  guide  to  the  degree  of  existing  acidosis  lies  in  the 
determination  of  the  daily  amount  of  sodium  bicarbonate, 
which  must  be  administered  in  order  to  render  the  urine  am- 
photeric. Normally  this  should  not  require  over  10  grams. 
In  acidosis  very  larg'e  amounts  are  necessary — frequently 
more  than  it  is  wise  to  administer  by  the  mouth  (Joslin  does 
not  favor  the  use  of  sodium  bicarbonate  as  a  routine  treat- 
ment of  acidosis). 

The  ordinary  tests  for  sugar  in  the  urine,  as  well  as  the 
qualitative  tests  for  acetone  and  diacetic  acid,  are  so  well 
known  that  it  would  be  needless  to  describe  them.  The  cop- 
per tests  are  universally  used  on  account  of  their  convenience, 
but  in  doubtful  cases  it  is  wise  to  confirm  them  by  the  simple 
but  reliable  fermentation  method.  Recently  Benedict  has 
modified  Fehling-'s  test,  making  it  more  delicate  and  more 
reliable.  Solutions  of  slightly  different  composition  are  em- 
ployed for  the  quantitative  and  qualitative  estimations.  The 
qualitative  test  will  be  described  later,  since  with  the  Allen 
treatment  it  is  customary  to  entrust  the  frequent  analyses  to 
the  patients  themselves. 

Diabetes  is  practically  always  a  chronic  affection,  but  the 
presence  of  the  disease  may  long  be  overlooked,  and  only  be 
revealed  by  the  acute  onset  of  some  serious,  or  even  fatal, 
complication.  In  children  the  disease  pursues  a  rapid  and 
usually  fatal  course,  but  Riesman  has  recenth^  described  mild 
cases  occurring  at  this  period  of  life.''"  In  young  adults  the 
most  typical  cases  of  the  disease  with  the  classical  symptoms 
— excessive  thirst,  polyuria  and  emaciation — are  observed.  In 
persons  of  middle  age  the  disease  may  be  associated  with 
obesity  or  gout,  and  pursue  a  relatively  mild  course.  Diabetes 
in  the  aged  is  also  marked  by  a  paucity  of  symptoms,  so  much 
so  that  many  aged  persons  will  not  tolerate  any  systematic 


520        DISEASES    OF    METABOLISM    AND    NUTRITION. 

treatment.  Nevertheless  at  this  period  of  Hfe  there  is  a  spe- 
cial tendency  to  vascular  and  pulmonary  complications. 

The  onset  of  the  disease,  though  rarely  acute  {e.g.,  fol- 
lowing nervous  shock),  is  usually  insidious.  The  patient's 
attention  may  be  drawn  to  its  existence  by  the  undue  fre- 
quency of  urination,*  itching-  of  the  skin,  and  rapid  emacia- 
tion, or  by  the  onset  of  complications  such  as  boils,  gangrene, 
failing-  vision  and  coma.  I  have  a  patient  under  observation 
at  present,  who  did  not  notice  any  deviation  from  her  usual 
health  until  the  onset  of  gangrene  of  the  toes.  In  many 
instances  the  physician  discovers  the  presence  of  the  disease 
in  the  course  of  routine  investigation  of  the  urine,  as  when 
examining  for  life  insurance.  From  a  therapeutic  standpoint 
diabetics  may  be  divided  into  the  mild,  the  moderately  severe 
and  the  severe,  divisions  which  are  based  on  tolerance  tests 
to  be  described  in  a  subsequent  paragraph. 

The  course  of  a  typical  case  in  a  young  adult  is  marked 
by  the  passage  of  large  quantities  of  pale  urine  (sometimes 
more  than  ten  times  the  normal  amount)  containing  varying 
percentages  of  glucose,  by  excessive  thirst  and  appetite,  and 
by  progressive  emaciation.  Less  important  symptoms  are 
dryness  of  the  skin,  itching,  flatulence,  flushing  of  the  cheeks, 
and  a  red,  denuded  tongue.  In  some  patients  the  contrast 
between  the  wasted  chest  and  the  distended  abdomen  is  strik- 
ing. The  duration  of  these  cases  is  on  the  average  less  than 
three  years.  (The  figures  of  Joslin^o  show  that  121  fatal 
cases  under  30  years  of  age  had  an  average  duration  of  2.7 
years).  In  patients  over  30  the  average  duration  was  more 
than  twice  as  great. 

Diabetics  seldom  die  from  the  simple  progress  of  the  dis- 
ease itself.  They  either  fall  a  prey  to  acid  intoxication  (nearly 
two-thirds  of  the  cases),  or  to  some  associated  or  complicat- 
ing acute  or  chronic  disease.  The  most  common  complicating 
[diseases  are :  cardiovascular  and  renal  afi^ections,  cancer,  pul- 
monary tuberculosis,  pneumonia  and  septic  conditions,  like 
gangrene  and  erysipelas. 

The  advent  of  acid  intoxication,  which,  as  mentioned,  car- 
ries  off   approximately   two-thirds   of    our   patients,    may    be 


*  If  this  is  aljsent  one  may  speak  of  "diabetes  decipiens." 


DIABETES    MELLITUS.  521 

g^radual,  with  frank  warning-  symptoms,  or  it  may  be  quite 
unheralded.  The  detection  in  the  urine  of  acetone,  diacetic 
acid,  and  increasing  amounts  of  ammonia  may  forewarn  us  of 
danger  in  season  to  permit  the  institution  of  preventive  meas- 
ures (administration  of  sodium  bicarbonate,  fasting).  Clinic- 
ally, malaise,  vertigo,  drowsiness,  and  epigastric  distress  may 
precede  the  onset  of  the  typical  dyspnea,  stupor  and  coma. 
(Joslin^i  says  that  the  occurrence  of  the  following  symptoms 
demand  investigation :  "anorexia,  nausea,  vomiting,  restless- 
ness, unusual  fatigue,  excitement,  vertigo,  tinnitus  aurium, 
drowsiness,  listlessness,  discomfort,  painful  or  deep  breath- 
ing.") The  coma  is  differentiated  from  that  of  uremia  by 
examination  of  the  urine,  and  by  the  peculiar  deep,  rapid,  but 
regular  breathing  ("air  hunger").  This  differs  entirely  from 
Cheyne-Stokes  breathing,  as  well  as  from  Biot's  respiration, 
both  of  which,  however  unlike  each  other,  are  characterized 
by  intervals  of  apnea.  Some  persons  with  a  well-developed 
sense  of  smell  can  distinguish  the  "fruity"  odor  of  acetone 
from  the  urinous  odor  of  uremia.  The  importance  of  the 
determination  of  the  CO2  tension  of  the  alveolar  air*  and  of 
the  blood  has  been  referred  to  above.  After  diabetic  coma 
is  well  developed  the  patient  seldom  recovers ;  this  is  in  strik- 
ing contrast  to  uremia,  in  which  active  therapeutic  interfer- 
ence is  often  successful. 

Some  of  the  minor  symptoms,  as  well  as  the  complications 
of  diabetes,  are  classified,  and  in  certain  instances  briefly 
characterized  in  the  paragraphs  which  follow. 

The  mental  state  of  diabetics  tends  toward  depression  and 
moroseness,  which  in  occasional  cases  may  amount  to  melan- 
cholia. Irritability,  restlessness,  and  impatience  under  dietetic 
restraint  are  also  said  to  be  characteristic.  Some  patients 
indulge  secretly  in  carbohydrate  food  in  spite  of  the  strictest 
injunctions  to  the  contrary.  When  the  patients  are  intrusted 
with  the  examination  of  the  urine,  and  to  a  certain  extent 
with  the  regulation  of  their  own  diet,  there  is  less  difficulty 
on  this  score.  Peripheral  neuritis  is  a  common  complication, 
and  is  accompanied  by  the  usual  sig'ns :    pain,  numbness,  and 


*A  simple   instrument   for  the   estimation   of   the   CO2  tension   of   the 
alveolar  air  is  now  on  the  market.     (Hynson  and  Westcott.) 


522       DISEASES    OF    METABOLISM    AND    NUTRITION. 

loss  of  reflexes.  In  some  cases  tabes  is  simulated,  on  account 
of  the  coexistence  of  optic  atrophy  and.  bilateral  neuritis  of 
the  lower  extremities.  Diabetes  is  one  of  the  conditions 
which  may  cause  bilateral  sciatica.  Disturbances  of  vision 
and  of  hearing-  are  frequent  symptoms  or  complications  of  this 
malady.  According  to  Saundby^-  the  following  are  the  most 
important  causes  of  diabetic  failure  of  vision :  weakness  of 
the  muscles  of  accommodation,  amblyopia  and  cataract. 

There  are  no  very  distinctive  changes  in  the  blood  in  dia- 
betes aside  from  the  increased  percentage  of  sugar  and  the 
presence  of  an  undue  amount  of  emulsified  fat  (lipemia).  In 
the  serum  the  latter  may  rise  like  cream.  The  cause  and 
significance  of  the  latter  phenomenon  is  not  understood 
(Bloor). 

Diabetes  does  not  ordinarily  lead  to  endocarditis,  and  only 
rarely  leads  to  pericarditis,  but  fatty  heart,  hypertrophy  and 
dilatation  of  the  heart,  and  vascular  sclerosis  are  common 
incidents  of  the  disease  which  give  rise  to  serious  symptoms : 
dyspnea,  anginoid  pains,  gangrene,  and  sudden  death. 

Pneumonia  is  the  most  frequent  respiratory  complication  of 
diabetes.  It  may  be  either  croupous  or  catarrhal  in  type,  and 
may  terminate,  more  frequently  than  in  normal  persons,  in 
gangrene  or  in  abscess.  Other  pulmonary  complications  are 
emphysema,  edema,  infarct  and  pleurisy. 

Ordinarily  the  mouth  is  dry,  the  tongue  and  lips  are  red, 
and  the  gums  inflamed.  Pyorrhea,  dental  caries,  and  toothache 
are  frequently  encountered.  The  large  quantities  of  water 
and  of  coarse  food  often  ingested  lead  to  dilatation  of  the 
stomach  and  catarrhal  conditions  of  the  stomach  and  bowels, 
accompanied  by  dyspeptic  symptoms,  and  by  constipation  or 
diarrhea.  In  rare  instances  the  clinical  picture  of  diabetes  is 
characterized  by  pigmentation  of  the  skin  and  symptoms  of 
cirrhosis  of  the  liver — hence  the  term  "bronzed  diabetes." 

Chronic  dififuse  nephritis  is  a  frequent  complication,  but 
hyaline  changes  in  the  kidney  of  less  serious  import  are  a 
common  cause  of  albuminuria.  Acute  nephritis  is  very  rare 
(3  cases  in  10,000 — von  Noorden).  The  irritating  quality  of 
the  urine  causes  pruritus  vulvae  in  women  and  balanitis  in 
men.  Women  are  frequently  sterile,  or  if  they  become  preg- 
nant are  likely  to  aljort.     Where  abortion  has  not  occurred 


DIABETES    MELLITUS.  523 

spontaneously  its  induction  has  been  urged  as  a  life-saving 
measure  for  the  mother.  With  the  starvation  treatment  Jos- 
lin^s  believes  that  pregnancy  can  often  be  carried  through  to 
a  successful  termination.  In  men  diabetes  may  cause  im- 
potence. 

Rapid  wasting  of  the  subcutaneous  fat,  in  spite  of  the 
ing'estion  of  enormous  amounts  of  food,  is  one  of  the  striking- 
features  of  severe  diabetes.  Complications  affecting  the  skin 
and  its  appendages  are  peculiarly  common.  Eczema,  derma- 
titis, pruritis,  pigmentation,  xanthoma,  purpura,  boils,  carbun- 
cles, ulceration  and  gangrene  are  all  seen  with  more  or  less 
freqiiency.  The  nails  may  be  brittle,  the  hair  harsh  and 
scanty,  and  the  skin  dry.  Occasionally,  on  the  other  hand, 
profuse  sweats  are  encountered.  Recently  purulent  arthritis 
of  the  knee  was  observed  in  a  case  of  diabetes. 

TREATMENT. 

Whether  it  concern  prophylaxis,  palliation  or  cure,  the 
treatment  of  diabetes  is  practically  synonymous  with  its  die- 
tetic management.  Treatment  by  drugs  has  retreated  more 
and  more  into  the  background,  and,  in  the  most  recent  mono- 
graph on  the  subject,  even  the  use  of  sodium  bicarbonate  is 
discouraged.  The  classic  dietetic  regime  has  been  perfected 
by  a  long  line  of  able  clinicians,  so  that  it  is  now  possible  to 
prescribe  a  diet  adjusted  to  the  tolerance  of  the  patient  with 
a  considerable  degree  of  ease  and  accuracy.  Although  our 
ideas  in  reference  to  diet  have  undergone  radical  changes  in 
the  last  three  years,  it  will,  nevertheless,  be  advisable  to  out- 
line the  treatment  hitherto  in  use,  and  then  to  consider  the 
innovations  introduced  by  Allen  and  others.  We  are  indebted 
to  Janeway  and  others  for  presenting  the  classic  method  of 
treatment  in  a  form  which  is  convenient,  and  at  the  same  time 
adapted  to  American  dietetic  habits.  The  aim  of  this  form 
of  treatment  is  to  adapt  the  diet,  primarily  the  sugars  and 
starches,  and  secondarily  the  proteins,  to  the  patient's  toler- 
ance, and  at  the  same  time  to  meet,  if  possible,  his  full  nutri- 
tive requirements,  according  to  the  usual  caloric  standards. 
In  cases  in  which  it  is  not  possible  to  rid  the  urine  of  sugar. 
additional  food  must  be  given  to  cover  the  caloric  losses. 
Cases   are   classified   as  mild,   moderately   severe   and   severe. 


524       DISEASES    OF    METABOLISM    AND    NUTRITION. 

The  mild  and  moderately  severe  cases,  if  put  on  a  carbohy- 
drate-free diet  (not  more  than  15  .grams),  containing  a 
liberal  proportion  of  protein  and  fat,  promptly  lose  their  gly- 
cosuria. The  moderately  severe  cases  will  not  tolerate  any 
considerable  addition  of  carbohydrates — not  more  than  1 
ounce  (30  Gms.)  in  the  twenty-four  hours.  In  the  mild  cases 
30  grams  or  more  may  be  taken  without  causing  glyco- 
suria. Janeway*^"^  recommends  that  carbohydrates  should  be 
added  in  the  form  of  ordinary  bread,  each  increment  consist- 
ing of  1  ounce  or  30  grams  (equal  to  15  Gms.  of  carbo- 
hydrate). Bread  is  much  more  acceptable  to  the  patient  than 
any  other  form  of  starch,  so  it  is  advisable  to  satisfy  this  nat- 
ural craving  so  far  as  possible.  In  order  to  permit  variety  Jane- 
way  has  prepared  a  table  of  "equivalents,"  showing  the  quan- 
tity of  various  carbohydrate  foods  which  correspond  to  1 
ounce  of  bread.  Thus  the  patient  is  permitted  to  substitute 
10  ounces  (296  mils)  of  milk,  or  5  ounces  (127  Gms.)  of  boiled 
oatmeal  for  each  ounce  (30  Gms.)  of  bread  allowed  (see 
Table  IV,  p.  527).  In  any  given  case  carbohydrate  is  gradu- 
ally increased  till  sugar  reappears  in  the  urine.  The  patient  is 
then  put  on  a  strict  diet  for  a  day  or  two,  and  thereafter  is 
permitted  to  take  two-thirds  or  three-fourths  of  his  ascer- 
tained tolerance. 

In  the  severe  cases  the  patient  does  not  become  sugar-free 
when  placed  on  a  strict  diabetic  diet.  The  urine  continues  to 
show  sugar  in  considerable  amounts,  and  very  often  diacetic 
acid  and  acetone.  In  severe  cases  it  is  the  rule  to  reduce  the 
carbohydrate  gradually,  as  sudden  reduction  is  liable  to  in- 
crease the  acidosis.  In  this  type  of  case  sugar  is  formed  from 
protein,  and  it  is,  therefore,  important  to  restrict  the  protein 
to  a  moderate  extent  as  well  as  the  carbohydrate. 

"Hunger  days"  (Naunyn)  and  "green  da3^s"  (von  Noor- 
den)  are  often  introduced  at  intervals  of  a  week  or  less  to  aid 
in  controlling  the  glycosuria.  A  considerable  percentage  of 
the  severe  cases  cannot  be  rendered  sugar-free  by  any  of  these 
methods,  and  are  in  danger  of  acid  intoxication  if  the  starches 
are  strictly  limited.  For  their  control  various  plans  of  treat- 
ment have  been  introduced,  which  have  one  feature  in  com- 
mon. This  is  the  administration  of  carbohydrate  in  some  form 
other  than  that  to  which  the  patient  is  accustomed.     These 


DIABETES    MELLITUS.  525 

Special  "cures"  include  milk,  rice,  potato,  oatmeal  and  raw 
starch®^  regimes.  The  oatmeal  diet,  introduced  by  von  Noor- 
■den,  has  had  the  most  extensive  vogue.  It  was  at  one  time 
supposed  that  oatmeal  starch  had  some  specific  difference 
which  distinguished  it  from  other  starches.  It  is  now  recog- 
nized that  the  beneficial  effects  of  this  diet  are  attributable 
to  its  small  protein  content,  and  to  the  presence  of  a  sufficient 
■amount  of  starch  to  prevent  the  development  of  severe  acido- 
sis. Very  frequently  this  diet  suffices  to  control  acidosis,  and 
to  improve  the  patient's  condition  temporarily,  but  the  glyco- 
suria may  be  aggravated.  In  many  cases  with  acidosis  sodium 
bicarbonate  is  added  to  aid  in  neutralizing  the  acidity,  ^ 
ounce  (15  Gms.)  a  day. 

The  following  are  taken  (with  unimportant  modifications) 
from  Janeway  (/.  c).  They  illustrate  the  points  that  have 
been  made,  and  will  be  found  useful  in  arranging  any  diabetic 
diet : 

I.     GENERAL    DIET    LIST. 

Eat  no  sugar  or  made  dishes  containing  sugar;  no  starchy 
foods,  such  as  bread  of  any  kind,  cereals,  potato,  rice,  peas, 
dried  beans  or  macaroni,  soups  or  sauces  thickened  with  flour, 
and  no  milk. 

Try  to  eat  every  day  much  butter,  bacon,  oil  on  salad,  and 
cheese,  especially  cream  cheese. 

A  small  amount  of  cream  (up  to  4  ounces  a  day)  may  be 
taken  in  coffee,  tea  or  cracked  cocoa  (Joslin).  Saccharin,  Yz 
grain,  may  be  used  for  sweetening. 

Whisky  with  water,  a  light  Rhine  wine  or  claret  may  be 
drunk  with  dinner  and  supper  (if  specially  ordered). 

Foods  Allowed.  Clear  meat  soups;  all  meats  except  liver; 
eggs  in  any  form ;  all  fish  except  oysters,  clams  and  scallops. 

As  desserts,  jellies  or  custards,  or  ice-cream  made  with 
cream  and'  eggs,  sweetened  with  saccharin,  and  flavored  with 
vanilla,  coffee  or  brandy. 

Cream,  cheese  and  vegetables  from  Joslin's  5  per  cent,  list 
(see  Table  VII). 

Mild  cases  are  allowed,  in  addition,  vegetables  and  fruits 
from  the  10  per  cent,  list  (Joslin),  3  ounces  daily. 


526        DISEASES    OF   METABOLISM    AND   NUTRITION. 

II.     STANDARD   STRICT   DIET. 
(  Janeway — Modified) . 

Breakfast.  Coffee  with  lj/4  ounces  cream;  2  eggs  cooked 
with  3^  ounce  butter;  3  ounces  ham. 

Lniiclicon.  Bouillon  with  1  raw  &gg;  3  ounces  sirloin  steak, 
chicken  or  leg  of  lamb ;  1  ounce  bacon. 

Vegetables  from  5  per  cent,  list,  2  tablespoonfuls,  with  3^ 
ounce  butter. 

Dessert  made  with  1  egg  and  lyi  ounces  cream. 

Six  ounces  wine,  or  1  ounce  whisky  or  brandy. 

(The  following  recipes  for  desserts  are  suggested :  Baked 
custard:  One  egg,  IJ^  ounces  of  cream,  2^  ounces  of  water; 
2  or  3  ^-grain  saccharin  tablets,  8  drops  of  vanilla  essence. 
Beat  up  well,  pour  into  a  buttered  dish,  grate  a  little  nutmeg 
on  top,  and  bake  twenty  minutes.  Coffee  ice-cream:  Xyz 
ounces  of  cream,  1}^  ounces  of  water;  1  ounce  of  strong 
coffee,  2  or  3  3^-grain  saccharin  tablets.  Dissolve,  add  1  egg, 
well  beaten.  Mix  in  a  saucepan  and  beat  slowly  with  stirring 
until  it  thickens.     Set  aside  until  cool,  then  freeze). 

Afternoon,  tea  with  3^  ounce  cream. 

Dinner.  Any  clear  soup;  3  ounces  fish  (salmon,  shad  or 
mackerel),  with  3^  ounce  butter;  ^4  pound  roast  pork,  beef, 
mutton,  turkey  or  lamb-chops. 

Vegetables  from  5  per  cent,  list,  2  tablespoonfuls,  with  J^ 
ounce  butter. 

Salad  with  ^  ounce  oil  in  dressing;  1  ounce  cheese  (Eng- 
lish, pineapple,  Swiss  or  full  cream)  ;  6  ounces  wine,  or  1 
ounce  whisky  or  brandy.     Demitasse  of  coffee. 

Protein    126  grams ;  504  calories. 

Fat   222  grams ;  1998  calories. 

Carbohydrate    15  grams ;  60  calories. 

Alcohol    30  grams;  210  calories. 

2772  calories. 

III.     STANDARD  DIET  WITH  RESTRICTED  PROTEIN. 
(Janeway — Modified) . 

Breakfast.  Coffee  with  1^^  ounces  cream;  2  eggs  with  J^ 
ounce  butter;  1  ounce  bacon. 

Luncheon.  Two  eggs;  1  ounce  bacon;  2  ounces  lamb-chops 
(1),  ham  (2),  beefsteak  (3),  chicken  (4),  or  fish  (5),  broiled 


DIABETES    MELLITUS.  527 

with  Yi  ounce  butter.  (Each  day  select  meat  with  same  num- 
ber for  luncheon  and  dinner.) 

Vegetable  from  5  per  cent,  list,  2  tablespoonfuls,  with  Yz 
ounce  butter. 

Dessert  made  with  1  egg,  1>^  ounces  cream. 

Six  ounces  wine,  or  1  ounce  whisky  or  brandy. 

Afternoon,  tea  with  >4  ounce  cream. 

Dinner.  Any  clear  soup;  Yx  pound  roast  pork  (5),  beef  (4), 
mutton  (3),  turkey  (2),  chicken  (1),  or  lamb  (1).  (Each  day 
select  meat  with  same  number  for  luncheon  and  dinner.) 

Vegetables  from  5  per  cent,  list,  2  tablespoonfuls,  with  ^ 
ounce  butter. 

Salad  with  Y^  ounce  oil  in  dressing;  1  ounce  cream  cheese; 
6  ounces  wine,  or  1  ounce  whisky  or  brandy.  Demitasse  of 
cofifee. 

Protein    82  grams ;  328  calories. 

Fat    215  grams ;  1935  calories. 

Carbohydrate    15  grams ;  60  calories. 

Alcohol    30  grams ;  210  calories. 

2533  calories. 


IV.    TABLE   OF   EQUIVALENTS. 
(Janeway). 

Amt.    in   ounces 
Per   cent.         equal  to  1  ounce  (30  Gms.) 

Breads.                                                                 carbohydrates.  ^f  ^jjite  bread. 

White   51-55  1 

All  other   47-53  1 

Rolls  and  biscuit  52-60  1 

Cornbread    46  l-]4 

Crackers,  average  69-72  54 

Cereals. 

Oatmeal,  boiled  11.3  S 

Hominy,  boiled    17.8  3 

Macaroni,  boiled  15.8  3-}i 

Rice,   boiled    25.4  .    2-^ 

Tubers  and  Legumes.  * 

Potatoes,    cooked    18-20  3 

Parsnips    13  4 

Beans,  baked    20  2-^ 

Beans,  lima,  cooked  20  2-54 

Peas,  green,  cooked  15  3-^ 


528       DISEASES   OF   METABOLISM   AND   NUTRITION. 

_  Amt.    in   ounces 

l^r.  *5f"':-        equal  to  1  ounce  (30  Gms.) 
carbohydrates.  ^f  ^^^^^  ^.^ead. 

Milk.  -  4-S  10 

Fruits. 

Apples,  apricots,  and  pears  12-14  4 

Cherries    15  3->4 

Huckleberries    16  3-% 

Plums    20  2-y2 

Bananas     22  2->4 

Nuts. 

Filberts    12  4-^ 

Almonds   15  3-J4 

Peanuts    22  2-^ 

Additional  allowances  for  mild  cases :  List  of  vegetables 
and  fruits  with  less  than  12  per  cent,  carbohydrates ;  3  ounces 
of  any  one  of  these  may  be  taken  daily. 

Vegetables  5  to  10  per  cent.:  Onion,  squash,  turnips,  okra, 
carrots. 

Fruits  below  12  per  cent.:  Lemons,  watermelons,  strawber- 
ries, gooseberries,  muskmelons,  cranberries,  blackberries,  cur- 
rants, grapefruit,  oranges,  raspberries,  sour  apples. 

Nuts:    Butternuts,  hickorynuts,  walnuts. 

V.    GREEN  DAYS, 
(von  Noorden — Janeway). 

Breakfast.    One  egg,  boiled  or  poached ;  cup  of  black  coffee. 

Dinner.  Spinach  with  a  hard-boiled  egg;  y2  ounce  bacon; 
salad,  with  Yi  ounce  oil ;  6  ounces  of  wine  or  1  ounce  of  whisky 
or  brandy. 

4.30  P.M.     Cup  of  beef-tea  or  chicken-broth. 

Supper.  One  egg,  scrambled,  with  tomato  and  a  little  but- 
ter; ^  ounce  bacon.  Cabbage,  sauerkraut,  string-beans  or 
asparagus.     Cup  of  tea. 

One-half  ounce  of  sodium  bicarbonate  in  the  twenty-four 
hours. 

The  treatment  by  prolonged  fasting  was  popularized  in 
France  by  Guelpa,^^  who  employed  it  in  connection  with  free 
purgation,  not  only  for  diabetes,  but  also  for  other  chronic 
conditions,  all  of  which  he  attributed  to  "autointoxication." 
In  the  intervals  between  fasts — he  usually  repeated  them  sev- 
eral times — he  employed  a  milk  or  a  strict  carbohydrate-free 


DIABETES    MELLITUS.  529 

diet.  He  did  not  think  it  was  necessary  to  keep  the  urine  con- 
stantly free  from  sugar  in  the  early  stages  of  treatment.  He 
and  his  followers  obtained  brilliant  results  in  many  cases.  Dr. 
Allen,*^''  on  the  basis  of  careful  animal  experiments,  adopted 
Guelpa's  method  of  prolonged  fasting,  and  followed  it  up  by 
a  very  strict  diet,  consisting  principally  of  green  vegetables. 
He  first  tested  the  carbohydrate  tolerance  by  giving  increas- 
ing amounts  of  green  vegetables,  etc.,  and  then  in  succession 
the  protein,  and,  if  necessary,  the  fat  tolerance.  If  during  the 
tolerance  tests  sugar  reappeared,  he  introduced  a  single  fast 
day,  and  reduced  the  particular  foodstuffs  by  a  safe  margin. 
He  aimed  to  give  1  gram  of  protein  for  each  kilogram 
of  body  weight,  and  enough  fat  to  maintain  the  nutrition,  if 
this  were  easily  possible.  Unlike  the  classic  treatment,  the 
starvation  treatment  does  not  make  a  point  of  maintaining  or 
increasing  the  body  weight.  If  the  patient  is  obese  it  is  even 
desirable  to  reduce  the  weight  considerably,  as  this  facilitates 
the  maintenance  of  tolerance.  The  diabetic  is  kept  continu- 
ously sugar-free,  and  acidosis  is  controlled  by  weekly  fasts. 
Since  no  attempt  is  made  to  supply  a  definite  number  of 
calories,  the  administration  of  extensive  amounts  of  fat  is  ren- 
dered unnecessary.  In  fact,  fats  are  increased  with  caution, 
as  the  addition  of  butter  or  olive  oil  may  cause  glycosuria  or 
ketonuria.  Allen^s  bases  his  treatment  not  on  any  hypothesis 
of  autointoxication,  but  on  the  theory  that  a  function,  if  im- 
paired, may  be  strengthened  by  rest.  Under  this  treatment 
the  carbohydrate  metabolism  usually  improves,  sp  that  in  time 
the  patient's  tolerance  is  materially  increased.  For  this  rea- 
son the  tolerance  should  be  tested  and  retested  at  long  inter- 
vals, and  the  diet  readjusted  in  relation  to  the  new  findings. 
In  order  to  carry  out  this  rather  elaborate  treatment,  it  is 
necessary  for  the  urine  to  be  frequently  examined.  Both 
Allen  and  Joslin  believe  that  it  is  better  for  the  patient  to 
make  these  tests  himself,  which  he  may  readily  do  by  Bene- 
dict's qualitative  method. 

VI. 

Benedict's  solution  is  permanent,  and  at  the  same  time  ten 
times  as  sensitive  to  sugar  as  is  Fehling's  solution.  Chloro- 
form, uric  acid,  and  creatinin  do  not  interfere  with  the  test : 

34 


530       DISEASES   OF   METABOLISM   AND   NUTRITION. 

Copper  sulphate   (pure  crystallized)    17.3 

Sodium  citrate   173.0 

Sodium  carbonate  (crystallized) 200.0 

Distilled  water   ad  1000.0 

"(The  citrate  and  carbonate  are  dissolved  in  about  700  mils 
of  water  with  the  aid  of  heat,  and  the  mixture  poured  into  a 
large  beaker.  The  copper  is  dissolved  in  about  100  mils  of 
water,  and  poured  slowly  and  with  constant  stirring-  into  the 
first  solution.  The  mixture  is  then  cooled  and  diluted  to  1 
liter — quart.) 

For  the  detection  of  glucose  in  urine,  5  mils  of  the  reagent 
are  placed  in  a  test-tube,  and  8  to  10  drops  (not  more)  of  urine 
added.  Heat  to  vigorous  boiling  for  one  or  two  minutes,  and 
allow  to  cool.  In  the  presence  of  glucose  the  entire  body  of 
the  solution  will  be  filled  with  a  precipitate,  which  may  be  of 
a  red,  yellow  or  greenish  tinge.  If  the  quantity  of  glucose  be 
under  0.3  per  cent,  the  precipitate  forms  only  on  cooling.  If 
no  sugar  be  present,  the  solution  remains  clear  or  shows  a 
faint-blue  turbidity.  It  is  often  more  convenient  to  place  the 
test-tubes  in  a  beaker  of  boiling-  water,  where  they  should 
remain  for  five  minutes.  If  sugar  reappears,  the  patient  is 
instantly  to  take  a  fast  day  in  bed,  and  then  to  reduce  the  diet 
somewhat  below  the  previous  limit.  Additional  fast  days  are 
advised  every  week  or  two,  and  the  patient  is  weighed  weekly 
to  avoid  increase  in  weight.^*^ 

SUMMARY    OF    DIETETIC    TREATMENT.™ 

"Preparation  for  Fasting. — In  very  severe,  long-standing,  complicated 
obese,  and  elderly  cases,  as  well  as  in  all  cases  with  acidosis,  without 
otherwise  changing  habits  or  diet,  omit  fat,  after  two  days  omit  the 
protein,  and  then  halve  the  carbohydrates  daily  until  the  patient  is  taking 
only  10  grams ;  then  fast.     In  other  cases  begin  fasting  at  once. 

'"Fasting. — Fast  four  days,  unless  sugar-free  earlier.  Allow  water 
freely;  tea,  coffee,  and  clear  meat  broths  as  desired. 

"Intermittent  Fasting. — If  glycosuria  persists  at  the  end  of  four  days, 
give  1  gram  protein  and  >^  gram  carbohydrate  per  kilogram  body  weight 
for  two  days,  and  then  fast  again  for  three  days  unless  earlier  sugar-free. 
If  glycosuria  remains,  give  the  protein  as  above,  but  with  no  carbohydrate 
for  three  days,  and  then  fast  for  one  or  twoi  days  as  necessary.  If  there 
is  still  sugar,  give  protein  as  before  for  four  days,  then  fast  one,  and 
then  gradually  increase  the  periods  of  feeding,  one  day  each  time,  until 
fasting  one  day  each  week.  Uncomplicated  cases  rarely  fail  to  become 
sugar- free  by  this  method. 


DIABETES    MELLITUS.  531 

''Carbohydrate  Tolerance. — When  the  twenty-four-hour  urine  is  free 
from  sugar,  add  150  grams  of  5  per  cent,  vegetables  (3  per  cent,  avail- 
able carbohydrate).  The  approximate  content  of  carbohydrate  would  be 
5  grams,  and  not  7.5  grams,  due  to  the  presence  of  cellulose  and  the 
lower  percentage  of  starch  in  such  vegetables  as  lettuce.  Continue  to  add 
5  grams  carbohydrate  daily  in  this  form  up  to  20  grams,  and  then  add 
5  grams  every  other  day  in  the  form  desired  until  glycosuria  appears. 

"Protein  Tolerance. — When  the  urine  has  been  sugar-free  for  two 
days,  add  about  20  grams  protein  (3  eggs)  and  thereafter  IS  grams  pro- 
tein daily  in  the  form  of  meat  until  the  patient  is  receiving  at  least  1 
gram  protein  per  kilogram  body  weight,  or,  if  carbohydrate  tolerance  is 
zero,  only  ^  gram  per  kilogram  body  weight. 

"Fat  Tolerance. — While  testing!  the  protein  a  small  quantity  of  fat  is 
included  in  the  eggs  and  meat  given.  Add  no  more  fat  until  the  protein 
reaches  1  gram  per  kilogram  body  weight  (unless  the  protein  tolerance 
is  below  this  figure),  but  then  add  5  to  25  grams  daily,  according  to  pre- 
vious acidosis,  until  the  patient  ceases  to  lose  weight  or  receives  about 
30  to  40  calories  per  kilogram  body  weight. 

"Reappearance  of  Sugar. — The  return  of  sugar  demands  fasting  for 
tv;enty-four  hours,  or  until  sugar-free.  Resume  the  former  diet,  except 
that  the  carbohydrate  is  diminished,  one-half  until  the  urine  has  been 
sugar-free  for  one  month,  and  it  should  not  then  be;  increased  more  than 
5  grams  a  month. 

"Weekly  Fast  Days. — Whenever  the  tolerance  is  less  than  20  grams 
carbohydrate,  fasting  should  be  practised  one  day  in  seven ;  when  the 
tolerance  is  between  20  to  50  grams  carbohydrate,  upon  the  weekly  fast 
day  5  per  cent,  vegetables  and  one-half  the  usual  quantity  of  protein 
and  fat  are  allowed;  when  the  tolerance  is  between  50  and  100  grams 
carbohydrate,  the  10  and  15  per  cent,  vegetables  are  added  as  vv-ell.  If 
the  tolerance  is  more  than  100  grams  carbohydrate,  upon  weekly  fast 
days  the  carbohydrate  should  be  halved." 

The  following-  tables  are  taken  from  the  cards  issued  by 
Joslin  ;*  these  cards,  on  one  side,  give  an  outline  of  the  treat- 
ment similar  to  that  just  quoted,  and,  on  the  other,  furnish 
the  necessary  data  for  arranging  the  diet : 

VII. 

Strict  diet,  meats,  fish,  broths,  gelatin,  eggs,  butter,  olive  oil,  coffee,  tea, 
and  cracked  cocoa. 

Foods  arranged  approximately  according  to  per  cent,  of  carbohy- 
drates. 


*  For  sale  by  Thos.  Groom  and  Company,    105   State   Street,   Boston, 
Mass. 


532       DISEASES   OE   METABOLISM   AND   NUTRITION. 


Vegetables  (fresh  or  canned)  : 


5   per 

sent.* 

10  per  cent. 

15  per  cent. 

20  per  cent. 

Lettuce 

Tomatoes 

Pumpkin 

Green  peas 

Potatoes 

Cucumbers 

Brussels 

Turnips 

Artichokes 

Shell  beans 

Spinach 

sprouts 

Kohl-Rabi 

Parsnips 

Baked  beans 

Asparagus 

Water-cress 

Squash 

Canned 

Green  corn 

Rhubarb 

Sea-kale 

Beets 

lima  beans 

Boiled    rice 

Endive 

Okra 

Carrots 

Boiled 

Marrow 

Cauliflower 

Onions 

macaroni 

Sorrel 

Egg-plant 

Mushrooms 

Sauerkraut 

Cabbage 

Beet-greens 

Radishes 

Dandelion- 

Leeks 

greens 

String-beans 

Swiss  chard 

Brocali 

Celery- 

*  Reckon   available  carbohydrates   in  vegetables  of  5  per  cent,    group   as   3   per 
cent.;  of  10  per  cent,  group  as  6  per  cent. 


Fruits: 


5  per  cent. 

10  per  cent. 

15  per  cent. 

20  per  cent. 

Ripe  olives 

Lemons 

Apples 

Plums 

(20  per  cent,  fat) 

Oranges 

Pears 

Bananas 

Grapefruit 

Cranberries 

Apricots 

Prunes 

Strawberries 

Blueberries 

Blackberries 

Cherries 

Gooseberries 

Currants 

Peaches 

Raspberries 

Pineapple 

Huckleberries 

Watermelon 

Nuts: 


5  per  cent. 

10  per  cent. 

Brazil  nuts 
Black  walnuts 
Hickory 
Pecans 
Filberts 

15  per  cent. 

20  per  cent. 

Butternuts 
Pignolias 

Almonds 
Walnuts    (Eng.) 
Beechnuts 
Pistachios 
Pinenuts 

Peanuts 
Chestnuts 
(40  per  cent.) 

DIABETES    MELLITUS.  533 

Miscellaneous   (5  per  c-e.nt.)  : 

Unsweetened    and    unspiced    pickles,    clams,    oysters,    scallops,    I'lver, 

fish-roe. 

(30  grams  =  1  ounce)  P.  F.  C.  Cal. 

Contain   approximately  Gms.  Gms.         Gms. 

Oatmeal,  dry  wgt 5  2  20  120 

Meat    (uncooked,    lean)     6  3  0  50 

Meat    (cooked,   lean)    8  5  0  75 

Broth    0.7  0  0  3 

Potato   1  0  6  25 

Bacon    5  15  0  155 

Cream,  40  per  cent 1  12  1  120 

Cream,  20  per  cent 1  6  1  60 

Milk    1  1  1.5  20 

Bread    3  0  18  90 

Butter    0  25  0  225 

Egg  (one)    6  6  0  75 

Brazil    nuts    5  20  2  210 

Small  orange  or  ^  grapefruit.  0  0  10  40 
Vegetables,  5  and  10  per  cent. 

group    0.5  0      1  or  2    6  or  10 

Oysters    (six)    6  1  4  50 

For  the  satisfactory  measurement  of  diabetic  diets,  food 
scales  are  necessary, — at  least,  until  the  patient  is  thoroughly 
familiar  with  food,  and  particularly  carbohydrate  values. 
(The  "Harvard  Scale"  (Troemner)  is  suitable  for  the  pur- 
pose. Convenient  spring  scales  are  also  made  which  permit 
of  the  adjustment  of  the  scales  after  each  addition  of  food, 
and  thus  obviate  calculations.) 

If  the  diet  has  been  so  adjusted  that  sugar  is  banished 
from  the  urine  and  acidosis  controlled,  it  seems  probable  that 
the  disease  will  show  no  necessary  tendency  to  progress,  and 
toleration  will  improve  to  a  certain  degree.  Advantage  may 
be  taken  of  this  gain  to  increase  the  diet,  if  toleration  is 
retested  after  a  period  of  some  months.  On  the  other  hand, 
the  impaired  function,  since  it  has  a  pathologic  basis,  is  not 
likely  to  become  normal  again.  It  will  be  necessary,  there- 
fore, for  the  patient  to  maintain  a  careful  diet  for  the  balance 
of  his  life  as  the  price  of  continued  health. 

The  patient  with  mild  diabetes  may  usually  go  about  his 
work  without  interruption,  provided  that  he  adheres  to  the 
dietetic  regulations.  In  the  moderately  severe  and  severe 
cases  it  is  wise  to  admit  the  patient  to  a  hospital,  sanatorium, 
or  nursing  home  until  the  tolerance  tests  have  been  com- 
pleted, and  the  patient  has  become  thoroughly  accustomed  to 
the  dietetic  routine.    During  the  period  of  starvation,  in  cases 


534       DISEASES    OF   METABOLISM   AND    NUTRITION. 

in  which  this  method  is  necessary,  the  patient,  as  a  rule,  should 
be  kept  in  bed,  but  an  exception  may  be  made  in  the  case  of 
vigorous  young  adults,  who  may  be  allowed  to  be  about  the 
room.  After  a  patient's  toleration  has  been  determined  he 
may  be  dismissed  with  instructions  to  test  the  urine  daily,  and 
report  to  the  physician  every  week  or  two,  depending  upon 
the  severity  of  the  case.  The  reappearance  of  sugar  demands 
immediate  restriction  of  diet,  and  in  most  cases  a  day  of  fast- 
ing. It  is  important  that  the  patient  should  lead  a  regular, 
methodic  life,  as  free  as  possible  from  strain  and  excitement. 
Frequent  warm  baths  are  an  advantage  to  keep  the  skin  in 
good  condition.  It  is  particularly  important  that  the  genitals 
should  be  kept  perfectly  clean  and  dry,  for  the  urine,  as  long 
as  it  contains  sugar,  is  prone  to  cause  distressing  pruritus  or 
eczema.  Many  of  the  mild  cases  are  associated  with  either 
gout  or  obesity,  and  will  be  benefited  by  a  stay  at  some  well- 
regulated  watering-place,  where  they  may  indulge  in  open-air 
exercise,  and  have  the  benefits  of  a  restricted  diet,  mild  alka- 
line waters,  hydrotherapy  and  massage. 

One  of  the  newer  ideas  in  the  treatment  of  diabetes  con- 
cerns the  value  of  exercise.  Clinical  experience  thus  far  indi- 
cates that  vigorous  exercise  is  beneficial,  even  in  severe  cases 
on  a  restricted  diet.  It  appears  to  stimulate  metabolism  and 
increased  sugar  toleration. '^i 

The  drug  treatment  of  diabetes,  which  once  occupied  a 
prominent  place  has,  as  I  have  said,  been  relegated  to  the 
background.  (Forscheimer  holds  it  to  be  still  of  value  in  the 
20  per  cent,  of  cases  who  will  not,  or  can  not  take  treatment.) 
This  does  not  apply,  of  course,  to  ordinary  tonic,  laxative  or 
symptomatic  treatment,  which  may  be  employed  on  general 
principles  as  in  any  other  chronic  disease.  Sodium  bicarbo- 
nate is  widely  used  as  a  prophylactic  against  acidosis,  but  this 
practice  is  not  as  popular  as  formerly.  One-half  ounce  would 
be  an  average  dose  in  the  twenty-four  hours.  The  use  of 
sodium  bicarbonate  will  be  referred  to  again  under  the  treat- 
ment of  special  symptoms. 

Opium  is  the  drug  which  has  maintained  its  reputation 
best  in  the  specific  treatment  of  this  disease.  It  is  usually 
administered  in  the  form  of  the  crude  drug,  or  in  tlie  form  of 
codein.     There  is  no  question   that  this  drug  promotes  the 


DIABETES    MELLITUS.  535 

comfort  of  the  patient,  and  reduces  the  excretion  of  sugar 
temporarily.  But  its  use  must  almost  inevitably  lead  to  the 
establishment  of  the  opium  habit,  and  with  the  perfection  of 
the  modern  dietetic  treatment  its  use  is  inexcusable,  except 
in  occasional  advanced  or  hopeless  cases,  where  dietetic  re- 
striction is  impossible  or  cruel.  The  dosage  of  opium  and  its 
various  derivatives  naturally  does  not  differ  from  the  ordi- 
nary, but  with  prolonged  use  would  necessarily  have  to  be 
increased  to  obtain  results. 

Aside  from  opium,  other  sedatives,  such  as  antipyrin, 
phenacetin,  and  the  bromids,  have  enjoyed  popularity  in 
certain  quarters.  Thus  Guelpa  refers  to  a  method  of  treat- 
ment employed  by  one  of  his  colleagues  which  consisted  in 
the  alternate  use  of  antipyrin  and  arsenic.  By  this  combina- 
tion both  the  amount  of  sugar  and  quantity  of  urine  were 
diminished,  but  sugar  was  only  abolished  after  the  institution 
of  prolonged  starvation. 

Arsenic  was  formerly  a  favorite  remedy,  but  cannot  be 
credited  with  any  specific  effects.  The  use  of  pancreatin  and 
other  products  derived  from  the  pancreas  would  seem  to  have 
a  more  rational  basis,  in  view  of  the  well-established  pan- 
creatic theory  of  the  disease.  Unfortunately  experience  does 
not  indicate  that  these  extracts  have  any  specific  value.  In 
cases  in  which  the  pancreas  is  seriously  affected,  they  may 
supplement  the  external  secretion  of  this  organ  and  improve 
digestion. 

TREATMENT    OF    SPECIAL    SYMPTOMS    AND 
COMPLICATIONS. 

The  most  important  and  fatal  complication  of  diabetes  is 
diabetic  coma.  The  only  efl'ective  treatment  of  this  condition 
is  prophylactic.  This  demands  that  the  patient  be  kept  under 
constant  supervision,  so  that  any  tendency  to  acidosis  sug- 
gested by  the  symptoms  already  mentioned,  or  by  the  pres- 
ence of  the  ferric  chlorid  reaction  (Gerhardt's  test  for  dia- 
cetic  acid),  be  immediately  combated  by  the  administration 
of  carbohydrates  and  the  employment  of  liberal  doses  of 
alkali ;  or,  on  the  other  hand,  if  we  follow  the  newer  treat- 
ment, by  a  sufficient  period  of  starvation  to  eliminate  sugar 
and  to  reduce  th^  amount  of  the  fatty  acids.     \\'hen  food  is 


536       DISEASES    OF   METx^BOLISM    AND    NUTRITION. 

resumed  the  fats  should  be  kept  very  low.  If  possible  it  is 
advisable  to  estimate  the  quantity  of  beta-oxybutyric  acid, 
but  it  is  much  simpler  to  determine  the  carbondioxid  ten- 
sion of  the  alveolar  air  (Marriott's  or  Fredericia's  methods), 
or  of  th'e  blood  (van  Slycke's  method).  When  first  intro- 
duced the  alkali  therapy  awakened  great  hopes,  which  have 
not  altogether  been  sustained.  Those  who  use  the  Allen 
treatment  maintain  that  it  is  rarely  necessary.  The  most 
effective  method  of  administration  in  impending  coma  is  by 
intravenous  infusion.  Five  hundred  mils  of  4  per  cent,  sodium 
bicarbonate  in  physiologic  salt  solution  may  be  slowly  in- 
jected into  one  of  the  veins  at  the  bend  of  the  elbow,  and  this 
dose  may  be  repeated  within  twelve  hours,  if  necessary.  Sub- 
cutaneous injections  are  unsafe  on  account  of  local  irritation, 
or  even  necrosis,  consequent  to  such  procedures.  Alkali 
therapy  should  be  suspended  when  the  acid  reaction  of  the 
urine  is  abolished,  but  this  seldom  occurs.  When  coma  is 
fully  established,  treatment  is  usually  futile,  though  con- 
sciousness is  occasionally  restored  temporarily. 

Most  of  the  complications  of  diabetes,  such  as  neuritis, 
ocular  disturbances  and  skin  eruptions  may  be  prevented  or 
greatly  benefited  by  strict  dietetic  treatment.  Local  applica- 
tions or  operative  treatment  are  required  for  skin  eruptions, 
boils  or  carbuncles,  but  not  much  benefit  may  be  expected 
until  the  patient  is  rendered  as  sugar-free  as  possible.  Gan- 
grene usually  occurs  in  the  aged  in  whom  there  is  coincident 
arterial  disease.  Excellent  results,  both  in  limitingf  the  extent 
of  the  gangrene  and  in  promoting  healing  after  operation, 
have  been  recently  credited  to  the  starvation  method.  If  the 
gangrenous  areas  are  small,  and  there  is  no  tendency  to 
spreading  they  may  be  treated  expectantly  by  antiseptic  or 
aseptic  methods  until  a  line  of  demarcation  has  formed,  when 
a  conservative  operation  may  be  performed.  If,  however,  the 
disease  is  extending  rapidly,  and  there  are  evidences  of  exten- 
sive arterial  disease,  a  high  amputation  would  be  indicated. 

Pyorrhea  and  caries  should  be  combated  by  careful  toilet 
of  the  mouth,  including  cleansing  with  mild  antiseptic  solu- 
tions and  painting  the  gums  with  tincture  of  iodine.  In  neph- 
ritis there  will  l)e  reasons,  in  addition  to  those  already  men- 
tioned, for  restricting  the  protein, — a  fact  sufficiently  obvious 


DIABETES    INSIPIDUS.  537 

not  to  require  extended  discussion.  In  tuberculosis  it  is  a 
nice  question  between  the  dietetic  restriction,  essential  in  the 
treatment  of  diabetes,  and  the  overfeeding  desirable  for  tuber- 
culosis. It  is  more  important,  however,  to  get  rid  of  the 
sugar,  and,  coincidently,  to  combat  the  tuberculosis  by  rest 
and  fresh  air. 

Allen,  in  a  recent  lecture  at  the  College  of  Physicians  in 
Philadelphia  (November,  1916),  advised  bran  and  agar  bis- 
cuits for  patients  on  a  very  strict  diet.  These,  though  taste- 
less, serve  as  a  good  vehicle  for  fats,  and  are  valuable  to 
regulate  the  bowels.  Joslin'^2  gives  the  receipt  for  their 
preparation : 

Bran    '. 60  grams  (2i,  50  grs.) . 

Salt    i4f3  (0.92  mils). 

Agar-agar,  powdered  6  grams  (93  grs.). 

Cold  water 100  mils   (3.38f.S  ) . 

"Tie  the  bran  in  cheesecloth  and  wash  under  cold-water 
tap  until  the  water  is  clear.  Bring  both  agar-agar  and  water' 
(100  mils)  to  the  boiling  point.  Add  to  the  washed  bran  the 
salt  and  agar-agar  solution  (hot).  Mold  into  two  cakes. 
Place  in  a  pan  on  oiled  paper,  and  let  stand  half  an  hour; 
then,  when  firm  and  cool,  bake  in  a  moderately  hot  oven 
thirty  to  forty  minutes. 

"Naturally  the  bran  muffins  will  be  far  more  palatable  if 
butter  and  eggs  are  added.  This  may  be  done  provided  that 
the  patient  allows  for  this  in  the  diet.  If  the  patient  is  not 
upon  a  measured  diet,  then  considerable  latitude  can  be 
employed  in  making  the  bran  cakes." 

The  use  of  gluten  breads  and  other  diabetic  foods  has 
not  been  advised  in  the  text  because  they  are  unnecessary, 
unpalatable  to  most  persons,  and  often  unreliable.  Before 
using  any  particular  preparation  the  physician  should  consult 
reliable  analyses. ''^ 

DIABETES    INSIPIDUS. 

Diabetes  insipidus  is  a  rare*  chronic  disease  character- 
ized by  the  passage  of  excessive  quantities  of  pale  urine  of 


*  Futcher"-^  found  7  cases  among  17,042  patients  on  Dr.  Osier's  service 
at  the  Johns  Hopkins  Hospital. 


538       DISEASES    OF   METABOLISM   AND    NUTRITION. 

low  specific  gravity  and  free  from  pathologic  constituents. 
Minute  traces  of  albumin  or  sugar  may  be  present  in  excep- 
tional cases.  Two  varieties  of  the  disease  are  described:  (1) 
the  idiopathic,  which  is  believed  to  be  dependent  upon  func- 
tional inability  of  the  kidney  to  concentrate  urine,  and  (2)  the 
symptomatic  variety.  The  latter  is  dependent  upon  func- 
tional or  organic  changes  afifecting  the  central  nervous  sys- 
tem. Functional  polyuria  has  been  observed  in  hysteria  and 
following  psychic  causes,  e.g.,  "emotional  insult."  The  or- 
ganic variety  is  due  to  implication  of  the  base  of  the  brain 
as  the  result  of  trauma  (fracture),  meningitis  (syphilis),  or 
tumor  (secondary  carcinoma).  The  most  frequent  underlying 
disease  is  lues,  which  takes  the  form  of  a  gummatous  men- 
ingitis. Four  of  Futcher's  7  cases  were  due  to  this  cause. 
According  to  Cushing,'^^  symptomatic  polyuria  is  dependent 
on  either  injury  or  disease  of  the  posterior  lobe  of  the  pitu- 
itary, leading  to  increased  secretory  activity.  He  regards 
emotional  polyuria  as  an  expression  of  a  neurogenic  discharge 
of  hypophyseal  secretion.  Disease  of  the  floor  of  the  fourth 
ventricle  is  also  believed  to  be  a  cause  of  diabetes  insipidus, 
this  view  being  based  on  the  celebrated  experiments  of  Claude 
Bernard.  The  malad)^  is  more  common  in  the  young,  and  in 
those  with  a  family  history  of  metabolic  or  renal  disease. 

The  classic  symptoms  are  polyuria,  polydipsia  and  poly- 
phagia. In  some  cases  the  large  appetite  may  be  replaced  by 
anorexia,  or  there  may  be  no  disturbances  of  the  appetite. 
Secondary  symptoms  are :  emaciation,  dryness  of  the  skin, 
diminished  perspiration,  distention  of  the  bladder,  constipa- 
tion or  diarrhea,  and  lumbar  pain  (Trousseau).  On  account 
of  the  lesion  of  the  base  of  the  brain  there  may  be  headache, 
ocular  changes  and  increased  reflexes.  In  men  there  may  be 
impotence,  and  in  women  scanty  menstruation  or  amenorrhea. 
In  infancy  diabetes  insipidus  may  lead  to  enuresis  (Still). 

The  quantity  of  urine  may  be  increased  to  ten,  or  occa- 
sionally even  to  twenty  or  thirty  times  the  normal  amount. 
It  is  not  uncommon  for  the  amount  of  urine  excreted  to 
exceed  the  volume  of  fluid  ingested.  The  difference  is  derived 
from  the  food  (see  chapter  on  Aletabolism),  or  temporarily 
from  the  tissues.  Restriction  of  fluid,  if  strictly  carried  out, 
may  reduce  the  quantity  of  urine,  but  causes  great  sutfering 


DIABETES    liNSIPIDUS.  539 

and  has  no  curative  value.  The  urine  is  almost  watery  in 
appearance ;  the  specific  gravity  usually  varies  between  1001 
and  1003.  The  ordinary  urinometer  will  suffice  for  clinical 
determinations,  but  slight  variations  cannot  be  accurately 
read. 

Acute  polyuria  is  without  question  a  mere  symptom. 
Chronic  polyuria  may  also  be  regarded  as  a  symptom,  though 
if  combined  with  other  manifestations  such  as  have  been 
described,  it  forms  the  symptom-complex  diabetes  insipidus. 
The  chief  causes  of  chronic  polyuria  which  have  to  be  ex- 
cluded are :  diabetes  mellitus  and  chronic  diffuse  nephritis. 
Hysteric  polyuria  is  usually  of  brief  duration,  although  recur- 
rent attacks  may  occur  over  a  long  period  of  time.  As  a  rule, 
diabetes  mellitus  is  easily  distinguished  by  the  high  specific 
gravity  of  the  urine,  the  glycosuria,  and  other  concomitant 
symptoms.  The  occasional  cases  of  diabetes  insipidus  in 
which  sugar  appears  from  time  to  time  probably  bear  no  rela- 
tion to  true  pancreatic  diabetes,  since  a  lesion  at  the  base  of 
the  brain  may  cause  polyuria,  either  with  or  without  sugar. 
In  the  polyuria  of  chronic  nephritis  either  albumin  or  casts 
may  occasionally  be  missed,  but  repeated  urinary  examina- 
tions and  blood-pressure  estimations  will  usually  settle  the 
■diagnosis.  In  the  differentiation  of  the  various  forms  of  dia- 
betes insipidus  particular  stress  should  be  laid  on  the  Was- 
sermann  test,  and  on  the  detection  of  symptoms  suggestive  of 
pituitary  disease. 

The  prognosis  of  diabetes  insipidus  is  entirely  dependent 
on  the  cause.  If  of  a  functional  nature  it  may  not  shorten 
life.'  Cases  are  mentioned  lasting  as  long  as  fifty  years.  Many 
examples  of  the  disease,  however,  are  dependent  upon  serious 
lesions  of  the  brain,  while  others  are  associated  with  acro- 
meg'aly,  Frohlich's  syndrome,  or  malignant  disease  of  the 
pituitary.  Several  cases  are  on  record  of  carcinoma  of  the 
pituitary,  secondary  to  cancer  of  the  breast. 

TREATMENT. 

Patients  with  this  disorder,  barring  complications,  may 
often  follow  their  usual  occupation,  providing  it  is  not  too 
strenuous.  A  case  of  this  sort  coming  under  observation  for 
the  first  time  should  be   carefully   studied   to   determine   its 


540       DISEASES    OF    METABOLISM    AND    NUTRITION. 

character  and  degree  of  severity.  To  do  this  efficiently  it 
will  be  necessary  to  confine  the  patient  to  bed,  either  at  home 
or  in  a  hospital.  Acromegaly  and  degeneratio-adiposo-geni- 
talis  should  be  excluded  by  a  careful  review  of  the  history  and 
detailed  examination.  In  the  latter  condition  there  is  usually 
an  increased  sugar  tolerance,  while  in  the  former  the  opposite 
condition  prevails.  This  point  may  be  determined  by  the 
administration  of  100  grams  (35  230  grs.)  of  glucose  in  the 
morning  on  a  fasting  stomach.  The  daily  quantity  of  the  urine 
should  be  measured,  and  the  effect  of  moderate  restriction  of 
water,  a  salt-free  diet,  etc.,  tested.  These  measures  are  oc- 
casionally beneficial.  As  mentioned  above,  an  occasional  trace 
of  albumin  or  sugar  will  not  make  the  diagnosis  of  nephritis 
or  diabetes,  but  it  is  important  to  use  every  means  to  exclude 
these  conditions.  A  history  of  syphilis  should  be  sought  for, 
and  a  Wassermann  test  made.  If  headache  or  ocular  symp- 
toms are  present,  the  eyes  should  be  examined  for  hemianop- 
sia, optic  neuritis,  etc.  As  these  patients  tend  to  emaciate 
they  should  be  allowed  a  plentiful  diet  with  an  adequate  sup- 
ply of  protein.  If  the  appetite  be  excessive  (polyphagia),  a 
light  lunch  may  be  given  between  meals.  On  account  of  the 
lack  of  perspiration  the  skin  is  dry  and  harsh,  and  should  be 
kept  in  good  condition  by  frequent  bathing,  and,  if  necessary, 
by  the  use  of  emollients  (cold  cream  and  the  like). 

In  cases  in  which  the  pituitary  is  incriminated,  pituitrin 
may  be  administered  subcutaneously,  7  to  15  minims  (0.5  to 
1.0  mil),  twice  daily,  with  the  expectation  of  reducing  the 
urinary  output  50  per  cent.'^^  This  treatment  is  deficient 
because  it  is  not  practicable  to  continue  it  more  than  a  few 
days,  but  it  may  be  of  use  during  an  exacerbation  of  the  dis- 
ease. Valerian  is  the  best  known  palliative,  and  in  large  doses 
reduces  the  amount  of  the  urine  very  considerably.  Trousseau 
administered  as  much  as  30  grams,  and  succeeded  in  reduc- 
ing the  urine  from  29  to  6  liters  (quarts),  but  induced  severe 
gastrointestinal  symptoms.  Ordinarily  30  grains  (2  Gms.) 
should  be  a  sufficient  dose.  The  drug  has  the  fault)  of  being 
intensely  disagreeable.  If  moderate  doses  be  employed,  the 
ammoniated  tincture  will  be  found  the  most  eligible  prepara- 
tion. Other  sedatives  have  a  similar  effect  in  reducing  the 
quantity    of    the    urine, — opium,    bromides,    cannabis    indica. 


ARTHRITIS.  541 

The  same  objections  may  be  raised  to  the  use  of  opium 
as  in  the  case  of  diabetes  mellitus.  Nitroglycerin  is  credited 
with  beneficial  effects  in  some  cases.  The  most  generally 
useful  drug,  however,  is  fluidextract  of  ergot  in  doses 
of  15  minims  (1  mil)  three  times  a  day.  Here,  again,  pro- 
longed use  is  not  without  danger.  Belladonna  does  not 
appear  to  be  of  much  value.  Aside  from  drugs  which  affect 
the  secretions  directly,  general  tonics,  such  as  nux  vomica, 
iron  and  arsenic,  are  useful.  If  the  diagnosis  of  syphilis  be 
certain,  "specific"  treatment  is  in  order:  mercurial  inunctions, 
potassium  iodid  and  salvarsan.  This  treatment  frequently 
relieves  the  headache  and  other  general  symptoms,  but  does 
not  appear  to  have  any  direct  effect  on  the  diuresis. 

Massage  and  hydrotherapy  are  of  value  to  improve  the 
general  condition,  while  electricity  (galvanic)  has  been  applied 
to  the  base  of  the  brain  with  the  hope  of  influencing  the 
pituitary  directly. 

ARTHRITIS. 

The  problem  of  arthritis  in  its  various  phases  is  an 
extremely  large  one,  and  has  been  the  subject  of  a  most 
voluminous  literature.  Only  in  the  relatively  recent  past  has 
it  been  classified  with  any  real  success,  and  even  now  authori- 
ties differ  as  to  the  best  subdivisions  of  the  types  encountered. 
For  the  general  purposes  of  treatment  the  subject  can  prob- 
ably be  best  approached  from  the  standpoint  of  the  following 
classification,  by  Barker,  of  diseases  of  the  joints  at  large. "^^ 
This  affords  a  very  comprehensive  summary  of  the  diagnostic 
features  of  the  various  arthritides,  and  the  writer  has  drawn 
freely  upon  it  and  the  other  works  referred  to : 

1.  The  congenital  arthropathies. 

2.  The  static  and  the  toxic  degenerative  arthropathies. 

3.  Arthropathies  of  circulatory  origin. 

4.  The  inflammatory  arthropathies   (arthritides). 

5.  The  neuropathic  arthropathies. 

The  first  two  varieties  find  no  place  in  a  textbook  on  med- 
ical treatment,  although  brief  references  will  be  made  to  the 
second  type.  Tlie  third  variety,  arthropathies  of  circula- 
tory origin,  demands  brief  reference  because  of  the  so-called 
"Bleeder's  Joint";   that   is   to   say,   an   articular  disturbance 


542       DISEASES   OF   METABOLISM  '  AND   NUTRITION. 

occasioned  by  hemorrhage  into  the  joint  in  a  patient  suffer- 
ing from  a  hemorrhagic  diathesis,  hemophiha,  purpura  or 
scorbutus.  The  treatment  of  this  condition  needs  no  special 
mention  beyond  the  treatment  of  the  underlying  cause,  except 
in  so  far  as  it  may  be  influenced  by  the  general  considerations 
of  rest,  local  applications,  and  so  on.  These  will  be  included 
in  the  treatment  of  the  other  arthritides.  The  neuropathic 
arthropathies,  next  in  the  foregoing  classification,  also  call  for 
no  particularization  here.  They  depend  for  their  treatment 
upon  recognition  of  the  underlying  disturbance,  and  deserve 
mention  only  to  direct  attention  to  the  general  applicability 
of  such  measures  as  rest,  support,  the  local  surgical  care  of 
trophic  sores  and  ulcers,  and  the  like.  These  several  varieties 
of  arthropathies  are  mentioned  because  their  symptoms,  to  a 
small  degree,  may  resemble  those  of  the  fourth  group,  and 
differential  diagnosis  is  at  times  necessary. 

The  inflammatory  arthropathies  included  in  the  above 
classification  are  the  essential  subject  of  consideration  here, 
and  form  a  most  important  chapter  in  medicine. 

Probably  in  no  other  department  of  medicine  has  there 
been  more  confusion  in  regard  to  nomenclature  than  here,  and 
only  in  the  very  recent  past  has  recognition  of  the  infectious 
origin  of  many  cases  of  arthritis  brought  some  order  out  of 
chaos.  Classification  of  the  inflammatory  arthritides  is  again 
dependent  largely  upon  the  viewpoint  of  the  individual  writer, 
and  may  be  referred  to  a  pathologico-anatomic,  etiologic  or 
clinical  grouping.'*'^  For  clinical  purposes  the  last  is  the  most 
useful  of  the  three,  and  will  be  used  here.  In  this  classifica- 
tion the  infectious  arthritides  are  divided,  in  so  far  as  our  pur- 
poses are  concerned,  as  follows : 

1.  The  true  chronic  gouty  arthritis. 

2.  The  primary  hypertrophic  osteoarthritis. 

3.  The  secondary  chronic  infectious  arthropathies  follow- 
ing various  bacterial  invasions. 

4.  The  so-called  primary  chronic  progressive  polyarthritis ; 
possibly  a  special  member  of  the  preceding  group. 

In  connection  with  these  four  main  groups,  several  special 
conditions  are  also  to  be  considered : 

(a)  Chronic  villous  arthritis  (the  villous  arthritis  of  Gold- 
thwait). 


INFECTIOUS    ARTHRITIS.  iJ43 

(b)  The  chronic  arthropathies  of  the  spine. 

(c)  Still's  disease. 

(c?)   Heberden's  nodes. 
(e)   Subcutaneous  fibroid  nodules. 

The  gouty  joint  will  not  be  taken  up  here,  as  it  comes 
properly  under  the  general  subject  of  "Gout"'   {q.  z'.). 

PRIMARY    HYPERTROPHIC    OSTEOARTHRITIS. 

Primary  hypertrophic  osteoarthritis  is  a  condition  which  is 
easily  recognizable,  and  occurs  most  frequently  in  late  adult 
life.  It  is  characterized,  in  general,  by  involvement  of  one  of 
the  larger  joints  of  the  body,  such  as  the  hip,  shoulder  or 
knee,  in  contrast  to  the  more  diffuse  processes  seen  in  other 
types;  occasionally,  however,  more  than  one  joint  is  affected. 
It  is  important  that  the  possibility  of  malignant  growth  be  not 
overlooked  in  these  cases,  especially  when  the  hip  is  con- 
cerned, and  the  .r-ray  is  useful  in  making  the  differentiation. 
The  pathologic  process  may  be  unaccompanied  by  other 
obvious  disturbances  of  health,  and  consists  of  atroph}^  of 
cartilage,  roughening  and  hypertrophy  of  the  bony  surfaces, 
exostoses,  lipping  of  the  joint-margins,  and  so  on.  This  con- 
dition has  probably  the  same  etiology  as  the  types  next  to  be 
described,  and  treatment  of  it  can  profitably  be  included  under 
treatment  of  them. 

INFECTIOUS    ARTHRITIS. 

It  is  in  connection  with  this  sub  variety  of  arthritis  that 
significant  advances  have  been  made  in  treatment.  If  the 
condition  known  as  acute  rheumatic  fever,  for  which  the 
salicylates  are  in  the  nature  of  a  specific,  be  eliminated  from 
consideration  here,  it  may  be  said  that  most  of  the  cases  of 
febrile  acute  non-traumatic  arthritis  belong  in  the  above  cate- 
gory, and  can  be  referred  to  a  focus  of  infection  somewhere 
in  the  body.  It  is  even  a  moot  question  whether  acute  rheu- 
matic fever  should  not  be  included  here  also. 

The  lesion  may  be  of  the  smaller  joints  alone,  or  of  the 
larger  alone,  though  in  general  one  or  more  joints  of  both 
kinds  will  become  affected  as  the  disease  progresses  or  be- 
comes chronic.    At  the  outset  the  site  of  the  arthritis  may  be 


544       DISEASES   OF   METABOLISM   AND   NUTRITION. 

painful,  swollen,  or  even  inflamed  to  inspection,  and  as  it 
becomes  more  chronic  and  spreads  to  other  joints  there  inter- 
vene atrophy  of  the  cartilage,  atrophy  and  rarefaction  of  the 
bone,  frequently  overgrowth  on  the  shaft  of  the  bone,  and 
thickening  and  contracture  of  the  capsule  and  tendons.  Later, 
as  the  articulations  become  anatomically  altered,  subluxation 
and  hyperextension  may  occur;  or,  if  there  be  much  lipping 
and  overgrowth,  limitation  of  motion,  or  even  complete  fixa- 
tion may  result.  There  may  be  efifusion  within  the  capsule  of 
the  joint.  At  any  time,  or,  indeed,  during  the  entire  course 
of  the  above  condition,  there  may  be  slight  fever  and  second- 
ary anemia  of  more  or  less  severity,  slight  leucocytosis,  and 
enlargement  of  the  lymph-glands.  The  clinical  picture  de- 
pends upon  the  degree  of  advancement  of  the  disease,  but 
when  this  is  well  established  the  patient  becomes  more  or  less 
bed-  or  chair-  ridden,  the  knees,  shoulders,  and  elbows  have 
only  limited  motion,  the  knees  are  enlarged,  the  hands  show 
irregular  swelling  of  the  knuckles  and  interphalangeal  joints, 
the  wrists  may  be  almost  ankylosed,  and  at  any  or  all  of  these 
sites  there  may  be  pain  upon  motion,  or  even  at  rest. 

In  what  is  undoubtedly  the  most  complete  single  work 
upon  the  subject  of  rheumatic  conditions,  Jones  and  Jones'^^ 
have  emphasized  the  importance  of  fibrositis  as  the  underlying 
and  characteristic  pathologic  phenomenon.  They  point  out 
that  it  is  the  fibrous  tissue  which  is  primarily  concerned  in 
these  conditions,  whether  the  disease  be  seated  in  the  muscle, 
nerve,  cartilage  or  bone.  They  discuss  the  so-called  "rheu- 
matic" states  under  the  general  term  "fibrositis,"  and  the  reader 
must  be  referred  to  this  exhaustive  work  for  a  full  presenta- 
tion of  this  pathology. 

In  this  class  of  cases  it  is  generally  recognized  that  the 
causative  agent  is  an  infection  somewhere  in  the  body.  The 
sites  of  this  infection  and  the  kinds  of  organisms  responsible 
for  it  are  very  varied. 

Arthritides  may  also  follow  infectious  diseases  such  as 
pneumonia,  typhoid  fever,  meningitis,  and  general  infections 
like  erysipelas  and  puerperal  infection,  and  one  attack  may 
suffice  to  render  the  subject  permanently  crippled  by  the  time 
subsidence  of  the  inflammation  has  occurred.  However,  this 
is  not  the  usual  picture,  and  in  general  it  may  be  said  that 


INFECTIOUS    ARTHRITIS.  545 

patients  suffering-  from  the  more  or  less  diffuse  symptoms 
above  described  carry  somewhere  in  their  bodies  a  source  of 
infection,  often  inconspicuous,  from  which  a  slow,  insid- 
ious absorption  takes  place.  This  focus  may  be  a  g"onococcal 
infection  of  the  genito-urinary  tract,  but  generally  a  less 
specific  type  of  organism  is  at  fault.  Bacteriologic  studies 
have  shown  that  streptococci  exceed  all  other  varieties  of 
organism  in  the  frequency  with  which  they  are  the  causative 
agents,  and  the  work  of  Rosenow  and  others  has  shown  that, 
of  the  various  streptococci,  the  Streptococcus  viridans  and  the 
Streptococcus  hemolyticus  are  those  most  usually  to  be  isolated. 
Experiments  have  indicated  that  strains  of  organisms  isolated 
from  various  foci  in  the  body  may  produce  analogous  lesions 
when  injected  into  experimental  animals,  and  that  there  ap- 
pears to  be  a  certain  degree  of  selective  affinity  in  regard  to 
them.'^o  Although  the  organisms  mentioned  seem  to  play 
the  most  important  role,  the  staphylococcus  may  be  equally 
potent,  and  it  must  not  be  overlooked  that  almost  any  organ- 
ism may  be  concerned,  including-  the  possibility  of  infection 
by  the  various  fungi  and  amebas.  Full  consideration  of  this 
important  question  is  impossible  here,  but  complete  presenta- 
tions are  available  in  the  writings  of  Billings,  who  has  been 
chiefly  instrumental,  in  conjunction  with  his  co-workers,  in 
expanding-  our  ideas  as  to  what  may  constitute  a  source  of 
infection. '^1  The  focal  disturbance,  caused  by  these  organ- 
isms, from  which  the  toxemia  arises  may  be  in  the  tonsils, 
accessory  sinuses  of  the  skull,  teeth,  gums,  alveolar  processes 
of  the  jaw,  ears,  appendix,  g-all-bladder,  genito-urinary  tract, 
or,  indeed,  anywhere  in  the  body. 

TREATMENT. 

In  view  of  wiiat  has  been  said,  therefore,  it  is  clear  that 
treatment  of  chronic  infectious  arthritis  depends  upon  the 
recognition  of  the  nature  and  site  of  infection,  and  the  steps 
taken  to  remove  it  or  to  combat  it,  if  removal  is  not  possible. 
Since  discovery  of  the  site  of  infection  is  of  the  first  impor- 
tance, it  is  well  to  consider  here  at  some  length  the  procedures 
necessary  to  that  end. 

Possibly  the  most  important  single  site  of  absorption  is  to 
be  found  in  the  teeth,  which  in  these  conditions  are  often  the 


546         DISEASES  OF  METABOLISM  AND  NUTRITION. 

seat  of  cavities.  The  roots  of  the  teeth  may  be  extensively 
affected,  although  giving  no  superficial  evidence  of  this  upon 
mere  inspection  of  the  mouth.  Obviously  this  condition  may 
vary  from  a  degree  of  slight  decay  to  that  in  which  the  teeth 
are  grossly  diseased  and  loose  in  their  alveolar  sockets.  The 
gums,  likewise,  may  be  greatly  or  slightly  affected,  and  pres- 
sure upon  them  may  cause  the  exuding  of  a  thin  pus ;  or  they 
may  be  spongy  and  bloody  upon  slight  pressure.  This  condi- 
tion of  pyorrhea  alveolaris  may  be,  in  itself,  sufficient  to  induce 
and  to  perpetuate  symptoms  of  arthritis,  and  hence  it  demands 
vigorous  treatment.  Accumulations  of  tartar  upon  the  teeth 
should  be  removed,  and  the  gums  brought  into  healthy  condi- 
tion by  frequent  cleansing  of  the  mouth,  the  removal  of  tartar 
from  the  teeth,  the  use  of  weak  hydrogen  peroxid,  astringent 
mouth-washes,  argyrol  in  50  per  cent,  strength,  application  of 
tincture  of  iodin,  etc.,  preferably  under  the  direction  of  a 
good  dentist;  notwithstanding  consistent  efforts,  much  time 
may  be  required  to  restore  conditions  to  normal. 

Recently  Barrett  and  Smith^^  have  described  the  occur- 
rence in  gums  thus  affected  of  an  ameba  which  they  describe 
as  the  Entameba  huccalis.  Basing  the  thought  upon  the  results 
seen  in  other  forms  of  amebiasis,  the  use  of  emetin  hydro- 
chlorid,  the  alkaloid  of  ipecac,  has  been  advocated  in  pyor- 
rhea, with  alleged  successful  results  in  many  instances.  It  is 
given  subcutaneously  in  doses  of  about  ^  grain  (0.0324  Gm.) 
daily.  Some  few  disastrous  consequences^^  have  followed 
its  use  in  doses  of  Ij^  grains  (0.0972  Gm.)  daily,  and  care 
must  be  exercised  that  it  be  not  administered  longer  or  in 
larger  dosage  than  required.  It  may  also  be  injected  locally 
between  the  tooth  and  the  gum  in  amounts  of  about  1  drop 
of  a  half  of  1  per  cent,  solution.  In  any  event,  it  should  be 
accompanied  by  the  measures  designed  to  promote  the  hygiene 
of  the  mouth — already  noted.  It  not  infrequently  happens 
that  steps  taken  to  rectify  infectious  conditions  of  the  above 
nature  are  not  complete,  even  when  the  patient  has  consulted 
a  dentist,  and  apparently  all  offending  members  have  been 
removed.  Under  these  conditions  the  desired  improvement 
will  not  take  place,  from  which  it  follows  that  a  more  thorough 
search  must  be  made  to  detect  the  site  of  trouble.  To  this 
end  the  .ar-ray  is  of  great  value,  and  it  is  indeed  a  debatable 


INFECTIOUS   ARTHRITIS.  547 

point  whether  it  should  not  be  used  as  a  routine  step  in  every 
case  where  search  is  made  in  the  teeth  for  a  site  of  possible 
infectious  absorption.  X-rays  of  the  teeth  made  in  groups  of 
two  or  three,  by  means  of  films  placed  in  the  mouth,  will 
show  grossly  diseased  processes  that  have  escaped  detection 
after  the  most  thorough  examinations  by  other  means.  Be- 
tween the  root  of  the  tooth  and  its  alveolar  socket  there  may 
be  an  apparently  trifling  space  more  or  less  filled  with  carious 
material,  merely  the  result  of  tartar.  This  condition  may 
extend  to  the  frank  formation  of  pus  which  collects  at  the 
root  of  the  tooth  as  in  a  pocket.  The  root  of  the  tooth  may 
also  give  further  evidence  of  disturbance  in  an  irregularity  of 
its  outline  and  rarification  of  its  substance.  The  alveolar 
processes  themselves  may  share  in  this  pathology,  and  un- 
dergo a  distinct  shrinkage  along  the  axis  of  the  tooth. 

Space  is  given  to  the  consideration  of  these  points,  because 
of  the  extreme  likelihood  that  they  may  be  overlooked,  and 
too  much  emphasis  cannot  be  placed  upon  the  importance  of 
having  suspicious  cases  studied  by  both  dentist  and  rontgen- 
ologist in  the  most  thorough  manner. 

In  the  experience  of  critical  observers  it  is  sometimes 
necessary  to  force  the  issue  as  to  whether  or  not  a  given 
tooth  or  its  socket  is  importantly  at  fault,  by  insisting  upon 
removal  of  the  tooth,  even  in  the  face  of  dental  opinion  to  the 
contrary. 

Foci  in  the  mouth  may  exist,  which  appear  trifling  on  their 
own  account  or  from  the  purely  dental  standpoint.  It  is  only 
when  they  are  viewed  from  the  larger  viewpoint  of  the  rela- 
tion they  bear  to  systemic  conditions,  however,  that  their 
true  importance  appears,  and  under  these  circumstances  the 
physician  may  have  to  overcome  considerable  opposition. 
Obviously  a  chain  is  as  strong  as  its  weakest  link,  and  since 
it  has  been  well  proved  that  otherwise  relatively  trifling  foci 
can  be  productive  of  serious  consequences,  one  cannot  be  sure 
of  having  done  one's  full  duty  until  there  remains  no  longer 
ground  for  the  slightest  suspicion  at  any  point. 

Just  as  the  teeth  may  be  the  site  of  suspected  trouble,  so 
the  tonsils  may  be  similarly  at  fault.  If  they  be  grossly 
implicated,  and  this  be  evident  upon  simple  inspection  of  the 
throat,  there  can  be  no  doul)t  as  to  the  steps  indicated.     How- 


548        DISEASES    OF    METABOLISM    AND    NUTRITION. 

ever,  in  the  experience  of  many  observers,  mere  inspection  is 
quite  insufficient  to  incriminate  or  to  absolve  them,  and  re- 
course must  be  had  to  a  more  thorough  examination  at  the 
hands  of  the  nose  and  throat  speciaHst.  Even  he  may,  at 
times,  fail  to  appreciate  upon  examination  alone  the  amount 
of  diseased  structure,  and  tonsillectomy  may  later  show  cen- 
trally located  septic  foci.  Relatively  trifling-  crypts  may  har- 
bor necrotic  material,  and  even  the  space  between  the  redup- 
lications of  tonsillar  tissue  may  suffice  for  the  lodgment  of 
food  imperfectly  removed  or  debris,  which  acts  as  a  culture 
medium.  The  importance  of  such  apparent  trifles  is  some- 
times to  be  seen  not  so  much  in  the  relation  they  themselves 
bear  to  the  systemic  joint  disturbance  as  in  their  cumulative 
effect  in  conjunction  with  other  apparently  trifling  foci  else- 
where. 

When  the  tonsils,  therefore,  are  found  to  be  affected  it  is 
very  doubtful  whether,  in  such  clear-cut  instances,  any  steps 
short  of  complete  removal  are  of  real  avail.  In  a  few  cases, 
especially  where  there  is  some  strong  contraindication  for 
removing  them,  expression  of  the  contents  of  the  tonsillar 
crypts  may  be  of  value. 

In  the  same  way  the  ears  should  be  made  the  subject  of 
a  most  critical  investigation  by  one  trained  in  this  line,  though 
in  general  the  ears  are  less  frequently  at  fault  than  are  the 
teeth  and  tonsils.  Examination  of  the  head  for  foci  of  infec- 
tion is  not  complete  unless  the  accessory  sinuses  of  the  skull 
are  also  included.  This  means  transillumination  by  the  spe- 
cialist and  several  ,r-ray  pictures  before  the  data  are  complete 
as  to  the  condition  of  the  ethmoid  air-cells  and  the  antrum  of 
Ilighmore. 

If  any  pathologic  process  be  found  at  any  of  these  sites,  it 
must,  of  course,  be  brought  under  control. 

The  appendix  is  also  a  possible  site  of  focal  sepsis,  and 
should  be  always  eliminated  as  a  possibility  in  this  connec- 
tion. X-ray  of  the  intestinal  tract  following  ingestion  of  bis- 
muth or  barium  may  reveal  anatomic  conditions  which  need 
attention. 

Rontgen-ray  examinations  have  revealed,  in  a  high  propor- 
tion of  cases  of  arthritis  which  are  not  frankly  infectious,  and 
even  in  some  cases  which  are,  that  the  colon  may  be  elon- 


INFECTIOUS    ARTHRITIS.  549 

gated,  rather  tortuous,  and  the  seat  of  stasis.  The  bismuth 
test-meal  may  be  notably  delayed  in  its  passage  through  the 
bowel.  These  factors  are  of  importance  chiefly,  perhaps,  in 
the  non-infectious  type  of  case  where  their  correction  may 
have  beneficial  results,  but  they  should  have  consideration  in 
all  obstinate  cases.  Sometimes  the  use  of  proper  abdominal 
support  in  the  form  of  a  belt  or  corset,  when  the  abdominal 
walls  are  flabby  and  protuberant,  may  prove  of  use.  Consid- 
erable attention  has  thus  been  given  to  the  restoration  of  the 
proper  anatomic  relations  in  such  cases,  but  in  general  these 
measures  are  likely  to  fall  short  of  the  desired  mechanical  cor- 
rection, and  are  useful  rather  in  connection  with  the  other 
fundamental  therapy  indicated  than  on  their  own  account 
alone. 

The  contentions  of  Sir  Arbuthnot  Lane**^  in  regard  to  the 
almost  exclusive  origin  of  the  various  arthritides  in  anatomic 
and  physiologic  aberrations  of  the  large  bowel  have  raised 
much  discussion,  and  much  division  of  opinion.  In  general, 
it  may  be  said  that  the  existence  of  the  relations  he  points 
out  cannot  be  denied  in  some  instances.  However  this  may 
be,  the  treatment  he  advocates,  namely,  ileocolostomy  and 
colectomy,  is  of  such  severity  as  to  render  its  general  applica- 
tion very  limited.  There  are  few  surgeons  who  care  to  pro- 
ceed to  such  extremes,  however  serious  the  condition  of  the 
patient  in  respect  to  his  arthritis.  Some  workers,  however, 
have  substantiated  Lane's  contentions,  and  reports  are  not 
lacking  in  which  great  benefit  has  followed  these  radical 
surgical  procedures. ^^ 

Returning  to  more  practicable  forms  of  therapy,  it  is  im- 
portant that  the  function  of  the  large  bowel  in  these  condi- 
tions of  stasis  be  assisted  with  the  mildest  medicinal  measures 
which  will  prove  effective,  such  as,  for  example,  petrolatum, 
cascara,  and  so  on.  The  well-known  action  of  agar-agar  in 
acting  as  a  non-absorbable  foreign  substance  to  stimulate 
peristalsis  obviously  suggests  it  as  a  useful  help.  It  may  be 
administered  as  such,  broken  up  and  sprinkled  through  oat- 
meal or  bread  and  puddings,  or,  preferably,  in  the  form  of 
little  wafers  now  to  be  had  at  leading  grocery  stores.*     Agar- 

*  Mansfield  Wafers :  Made  by  the  Mansfield  Laboratories,  Inc.,  5 
Appleton  Street,  Boston,  Mass, 


550       DISEASES    OF    METABOLISM    AND    NUTRITION. 

agar  absorbs  water  in  the  intestines,  and  so  greatly  increases 
in  size  as  materially  to  increase  in  volume  the  intestinal  con- 
tents. 

Another  field  of  attack  should  be  the  genito-urinary  tract, 
and  careful  examination  may  reveal  a  boggy  prostate,  the  site 
of  a  low-grade  infection.  Massage  of  this  gland  and  an 
examination  of  its  secretion  under  a  microscope  may  reveal 
the  presence  of  cellular  elements  in  undue  amounts,  or  even 
the  causative  organism  at  fault.  Similarly,  the  seminal  vesi- 
cles may  harbor  low-grade  infection.  In  women  the  cervix 
uteri  may  be  the  seat  of  a  semipurulent  discharge,  and  the 
glands  of  Bartholin  may  also  show  infection. 

It  is,  of  course,  chiefly  from  the  genito-urinary  tract  that 
arthritides  caused  by  the  gonococcus  may  originate.  Gono- 
coccal types  differ  not  at  all  in  principle  from  those  caused 
by  other  organisms,  though  clinically  they  differ  in  attacking 
principally  the  larger  joints,  such  as  the  knee  or  ankle.  Only 
rarely  are  the  smaller  joints  of  the  fingers  concerned  in 
chronic  cases,  unless  a  secondary  infection  by  streptococci  has 
occurred.  Vigorous  treatment  of  the  causative  gonorrheal 
infection  is,  of  course,  imperative. 

The  above-mentioned  sites  are  those  in  which  it  is  most 
likely  that  infection  may  be  harbored,  but  it  must  be  borne 
in  mind  that  it  may  exist  anywhere  in  the  body,  and  consid- 
eration must  be  given  to  all  other  portals  of  entrance,  such  as 
the  bladder,  pelvis  of  the  kidney,  and  so  on. 

Treatment  based  upon  the  above  considerations  will  often 
give  striking  results,  and  is  to  be  strongly  urged  as  the  logical 
procedure  to  be  followed.  If  the  patient's  general  condition 
is  unsatisfactory  for  any  necessary  operative  procedure  he 
should  be  prepared  with  as  little  delay  as  possible  to  with- 
stand it,  since  delay  invariably  means  greater  damage  to  the 
already  diseased  joints,  and  very  possibly  implication  of  other 
parts  as  well.  When  such  steps  as  the  above  are  being  taken, 
and,  indeed,  at  all  times  during  convalescence,  effort  should 
be  unsparing  to  improve  the  general  condition  of  the  patient 
by  means  of  good  food,  systemic  tonics,  fresh  air,  and  such 
exercise  as  he  is  easily  capable  of  without  undue  fatigue. 
The  gastrointestinal  tract  may,  or  may  not,  be  affected  in 
these  conditions,  and  forced  feeding  can  be  followed  in  ema- 


INFECTIOUS    ARTHRITIS.  551 

ciated  cases  only  within  the  limits  of  its  easy  function.  This 
must  be  kept  actively  in  mind,  since  derangement  of  the 
stomach  throug"h  overeating-  is  more  harmful  ihan  failure  to 
institute  forced  feeding'. 

It  is  common  knowledge  that  in  recent  years  the  use  of 
vaccines  in  a  large  variety  of  diseases  has  been  widely  ex- 
ploited, but,  perhaps,  in  few  other  conditions  have  they  been 
more  used  than  in  the  various  arthritides.  Out  of  the  extra- 
vagant -hopes  and  claims  for  these  measures  which  once 
obtained,  a  dispassionate  viewpoint  has  finally  been  evolved. 
It  seems  clear  that  vaccines  have  a  real,  though  limited  func- 
tion, in  combating  the  infectious  types  of  arthritis.  Funda- 
mentally, as  elsewhere  indicated,  the  causative  infection  must 
be  removed,  in  order  to  reach  the  cause.  However,  where  a 
joint  long  remains  the  seat  of  the  morbid  process  and  the 
exciting  agent  has  been  apparently  removed,  the  intelligent 
use  of  autogenous  vaccines  may  be  productive  of  distinct 
benefit.  Vaccines  should  never  be  used  as  a  substitute  for  the 
more  fundamental  therapy  of  removing  the  cause,  but  where 
this  is  difficult  or  impossible,  or  where  for  other  reasons  it  is 
desirable  to  help  in  the  modification  of  infectious  factors,  vac- 
cines may  serve  to  increase  the  resistance  of  the  individual 
toward  the  organism  at  fault. 

The  use  of  stock  vaccines  is  less  to  be  recommended,  but 
even  with  them  good  results  have  been  reported  by  some 
observers.  Pending  the  preparation  of  autogenous  vaccines 
from  a  determined  focus  of  infection  the  use  of  a  stock  prep- 
aration of  the  type  of  organism  isolated  is  sometimes  justifi- 
able. Complement-fixation  tests  may  be  useful  in  determining 
the  orglanism  responsible.  The  use  of  so-called  polyvalent 
stock  vaccines,  however,  made  from  a  combination  of  strains 
of  organisms  most  frequently  isolated  from  infectious  types 
of  arthritis  at  large,  and  having  no  necessary  specificitv  to 
the  case  at  hand,  is  obviously  in  the  nature  of  a  shot  in 
the  dark,  and  the  profession  has  everywhere  properly  dis- 
credited this. 

In  administering  vaccines  certain  principles  must  be  kept 
in  mind.  The  basis  on  which  they  act  is  that  in  these  low- 
grade  infections  the  economy  has  been  unable  to  develop  a 
degree  of  resistance  sufficient  entirely  to  overcome  the  invad- 


552       DISEASES    OF   METABOLISM    AND    NUTRITION. 

ing  organism.  By  suitably  timed  injections  of  dead  cultures 
of  the  organism  at  fault,  it  may  be  possible  to  stimulate  the 
system  to  a  heightened  defense,  or  offense,  against  it,  which 
results  finally  in  overcoming  the  development  of  the  organism. 
From  this  it  obviously  follows-  that  only  when  the  mechanism 
of  defense  is  still  active  and  capable  of  further  stimulation 
should  thought  of  the  use  of  vaccines  be  entertained,  and  it 
is  probably  for  this  reason  that  their  use  in  the  acute  over- 
whelming infections  has  been  disappointing.  In  pneumonia 
and  typhoid  fever  the  mechanism  is  probably  already  stimu- 
lated to  its  utmost.  Furthermore,  the  dosage  should  be  such 
that  a  real  stimulation  is  induced.  If  too  little  vaccine  be 
used,  the  effect  may  be  insufficient.  If  too  much  be  adminis- 
tered, there  may  be  added  a  further  burden  to  that  under 
which  nature  is  already  struggling.  The  best  criterion  of  the 
proper  dosage  is  probably  the  reaction  induced,  which  should 
be  definite,  and  yet  not  too  great  for  the  condition  of  the 
patient.  This  reaction  is  characterized  generally  by  some 
fever,  chilliness,  malaise,  or  even  an  exacerbation  of  all  symp- 
toms, together  with  soreness  at  the  site  of  injection,  but  these 
evidences  should  subside  within  a  period  varying  from  some 
hours  to  a  day  or  two,  depending  upon  their  severity.  It  must 
be  remembered  that,  although  the  type  of  organism  at  stake 
often  can  be  determined,  the  virulence  of  the  particular  strain 
cannot,  without  preliminary  experimentation ;  and  that  pru- 
dence demands  the  use  of  small  doses  until  the  degree  of 
reaction  is  clearly  ascertained.  Furthermore,  the  condition  of 
the  patient  must  be  such  that  there  is  reasonable  belief  that 
stimulation  of  the  body  defenses  is  probable.  Just  as  in  the 
presence  of  an  overwhelming  infection  the  defense  of  the  body 
is  already  at  its  maximum,  so  in  asthenic  states  the  defensive 
processes  may  be  so  low  that  attempts  to  stimulate  them 
result  only  in  adding  a  further  burden. 

For  these  reasons  no  single  dosage  can  be  recommended 
in  these  conditions,  but,  in  any  event,  the  initial  dose  should 
be  small  (say,  10  million  killed  micro-organisms),  and  should 
be  increased  with  successive  injections  in  proportion  tO'  the  reac- 
tion developed.  The  interval  between  injections  should  be  several 
days — not  more  than  ten — and  never  less  than  that. required 
for  ample   recovery  from  the   preceding  dose.     Usually  the 


INFECTIOUS   ARTHRITIS,  553 

reactions  eventually  grow  less,  despite  the  increase  in  dosage, 
and  when  the  effects  of  increasing  injections  have  been  prop- 
erly studied,  as  much  as  250  or  500  millions  may  be  employed 
with  benefit.  While  some  time  may  be  required  to  ascertain 
the  end-result  of  such  measures,  they  should  not  be  persisted 
in  after  reasonable  evidence  has  accumulated  that  benefit  is 
not  to  be  derived. 

Recently  the  treatment  of  arthritis  by  the  intravenous 
injection  of  foreign  proteins  has  been  introduced  with  some 
reported  success^^  in  acute  articular  rheumatism,  so-called, 
and  the  subacute  variety  of  arthritis.  Gonorrheal  arthritis  of 
from  two  months'  to  three  years'  duration  has  apparently  also 
been  benefited.  The  nature  of  the  reaction  effecting  these 
changes  is  not  yet  clear  to  the  authors  of  the  method,  and  its 
full  possibilities  and  limitations  await  further  investigation. 
The  method  practised  depends  upon  the  intravenous  injection 
of  2  mils  of  a  4  per  cent,  solution  of  proteose,  although  in  later 
experiments  typhoid  vaccine  was  substituted  for  the  proteose 
solution. 

The  vaccine  was  prepared  from  the  Rawlings  strain,  killed 
by  heating  to  55°  C.  (131°  F.)  and  preserved  by  0..5  per  cent, 
phenol.  The  dosage  varied  from  75,000,000  to  150,000,000, 
and  was  followed  by  more  or  less  reaction  in  the  shape  of 
leucocytosis,  chill  and  fever.  Injections  were  given  daily  in 
some  cases,  and  at  times  twelve  to  twenty-four  hours  sufficed 
for  the  joints  to  appear  normal.  No  ill  effects  were  reported 
as  a  consequence  of  the  injections. 

In  general,  medication  plays  but  a  small  role  in  these 
arthritides,  beyond  the  obvious  availability  of  agents  such  as 
iron,  strychnin  and  digitalis  when  indicated.  Certain  drugs, 
however,  have  a  larger  function,  and  it  would  be  improper  to 
omit  reference  to  the  very  real  value  of  arsenic,  either  in  the 
form  of  Fowler's  solution,  1  to  2  minims  (0.07  to  0.14  mils) 
after  meals,  or  as  sodium  cacodylate,  %  grain  (0.013  Gm.) 
after  meals,  in  a  certain  proportion  of  cases.  As  a  general 
tonic  in  those  rendered  anemic  by  the  chronicity  of  this  dis- 
ease it  is  of  great  use,  but,  more  specifically,  in  incipient  cases 
it  rnay  sometimes  be  sufficient,  in  conjunction  with  other  steps 
toward  regulating  hygiene,  to  dissipate  all  symptoms.  There 
are  many  individuals  living  upon  the  borderland  of  muscular 


554        DISEASES    OF  METABOLISM    AND    NUTRITION.' 

and  joint  disturbances  of  a  rheumatoid  nature,  in  whom  the 
interrupted  use  of  arsenic  maintains  their  health.  In  the 
writer's  -  experience  small  doses  are  best,  as  subjects  of 
arthritis  are  sometimes  very  susceptible  to  its  influence,  and 
show  especially  early  the  signs  of  its  therapeutic  limit. 

The  use  of  the  salicylates  and  aspirin  is  so  well  known  as 
to  require  little  emphasis  here.  Although  in  the  nature  of 
specifics  in  acute  inflammatory  rheumatism  proper,  they  are 
by  no  means  so  sure  a  panacea  in  the  chronic  rheumatoid 
affections,  but  their  influence  upon  pain  is  very  real  in  a  large 
majority  of  instances,  and  can  be  depended  upon  to  give  the 
patient  comfort  while  a  mor-e  fundamental  therapy  is  at- 
tempted. During  the  later  stages  in  hopeless  cases  they 
should  be  held  in  reserve  as  instruments  of  real  but 
limited  value,  and  potential  factors  of  serious  digestive  dis- 
turbance, if  improperly  used.  Furthermore,  they  not  infre- 
quently lose  their  effect  more  or  less  as  time  goes  on,  necessi- 
tating eventually  the  increased  dosage,  which  finally  upsets 
digestion.  Aspirin*  in  5-  or  10-  grain  (0.325  or  0.650  Gm.) 
doses  can  be  used  very  happily  in  advanced  cases  for  those 
emergencies  Vv^hen  the  patient  desires  to  make  a  particular 
effort,  or  when  an  unbroken  night's  sleep  is  important.  He 
should  be  encouraged,  however,  in  all  instances  to  g"et  along 
with  as  little  as  possible. 

The  iodids  have  long  been  in  vogue  in  connection  with 
arthritis,  and  while  it  cannot  be  definitely  stated  that  they  are 
of  no  avail,  the  benefit  to  be  derived  from  them  is  certainly 
very  small.  Their  greatest  effect  presumably  follows  full  dos- 
age, and  yet  it  is  of  the  first  importance  to  avoid  any  disturb- 
ance of  digestion  to  which  this  therapy  may  lead. 

Thyroid  extract  is  a  drug  which  has  accomplished  at  least 
temporary  benefit  in  a  certain  number  of  cases,  but  in  general 
its  use  is  ill-advised.  It  has  the  property  of  "hastening  metab- 
olism," and  in  some  degree  this  acts  analogously  to  exercise 
and  the  .r-ray,  and  may  1)e  followed  by  subjective  and  objec- 
tive improvement.  These  benefits  are  slight  and  infrequent, 
however,  and  are  negatived  by  the  inevitable  and  dangerous 


*  Aspirin    is   the   proprietary   name    for   acetyl-salicylic    acid,    which   is 
cheaper,  and  of  course  equally  efficient. 


INFECTIOUS    ARTHRITIS.  555 

nervousness  and  tachycardia  which  eventually  supervene  if 
its  use  be  long-  continued. 

The  use  of  an  extract  of  the  thymus  gland  has  also  been 
advocated. ^^  This  seems  to  be  entirely  harmless,  but  while 
some  success  with  it  has  been  reported,  later  observations 
have  not  seemed  to  bear  this  out,  at  least  in  the  writer's 
experience.  The  dosag'e  is  from  10  to  20  grains  (0.65  to  1.3 
Gm.)  three  times  a  day  over  a  long  period  of  time.  It  is  con- 
ceivable that  it  might  have  an  action  comparable  to  that  of 
thyroid  extract. 

For  many  years  it  has  been  the  custom  of  the  profession 
to  give  colchicum  and  lithia  in  these  joint  disturbances  which 
at  some  period  of  their  progress  were  formerly  mistaken,  and, 
indeed,  are  now  not  infrequently  mistaken,  for  gout.  Neither 
is  of  avail,  however,  and  need  not  be  considered.  The  use  of 
lithia  is  based  upon  erroneous  conceptions. 

Another  method  of  therapy  which  has  had  great  vogue,  and 
to  which  nearly  all  chronic  patients  have  at  one  time  or  an- 
other been  subjected,  is  that  based  upon  elimination.  It  is  the 
practice  of  some  clinicians  to  induce  free  action  of  the  bowels, 
but  there  is  no  virtue  in  the  purgation  which  is  sometimes 
advised. 

Whatever  the  type  of  arthritis  and  whatever  the  portal 
of  entrance  to  the  toxin,  elimination  can  rarely  keep  pace  with 
the  access  of  fresh  toxin,  and  should  never  be  pushed  to  the 
point  of  debilitating  the'  patient.  Water  should  be  freely 
taken,  but  only  upon  the  general  grounds  which  make  its  use 
always  advisable. 

One  means  of  inducing  heightened  elimination  has  been 
through  the  bath  and  sweat  processes,  so  much  and  so 
long  in  vogue  in  various  sanatoria,  both  here  and  abroad.  In 
certain  early  and  borderland  cases  it  is  highly  probable  that 
the  induction  of  free  diaphoresis  is  of  some  real  benefit,  and 
when  coupled  with  the  proper  conditions  of  hygiene  and  tlie 
like  it  may  stem  the  tide,  and  cause  the  subsidence  of  all 
symptoms  for  a  long  time,  if  not  permanently.  More  fre- 
quently, however,  patients  who  undergo  these  measures  im- 
prove at  the  time,  only  to  relapse  when  the  measures  are 
desisted  from  and  the  usual  manner  of  life  is  resumed.  Not 
infrequently  also  patients  suffer  harm,  which  may  be  perma- 


556        DISEASES    OF    METABOLISM    AND    NUTRITION. 

netit,  from  too"  prolonged  treatment  of  this  nature.  Above 
all,  depleting  and  exhausting  courses  of  baths  and  hydro- 
therapy are  to  be  avoided.  They  are  likely  to  add  to  the 
weakness  already  present,  and  to  produce  a  general  debility 
from  which  the  patient  may  be  long  in  recovering.  However, 
these  measures  have  a  real,  though  limited  place,  in  the 
therapy  of  arthritis,  provided  they  are  not  allowed  to  replace 
more  important  measures  directed  toward  removing  the  un- 
derlying cause  as  described  above. 

The  joints  may  also  be  the  subject  of  local  therapy  in  the 
form  of  baking,  massage  or  medicinal  applications.  These 
three  manoeuvres  have  in  themselves  no  curative  value,  but 
they  play,  nevertheless,  a  very  useful  part  in  conjunction  with 
other  more  important  measures.  In  most  cases  baking  gives 
considerable  subjective  relief,  but  it  is  to  be  practised  with 
due  care  that  the  patient  is  not  thrown  into  a  profuse  pers- 
piration or  M^eakened  by  being  too  long  subjected  to  it.  When 
the  joints  are  the  subject  of  such  passive  or  active  motion  as 
may  justifiably  be  attempted  during  convalescence,  baking 
will  be  found  to  render  them  much  more  flexible  for  these 
exercises,  so  that  more  can  be  accomplished  than  by  manual 
methods  alone. 

Massage  and  passive  or  active  motion  have  a  very  real 
function  in  these  conditions,  but  they  should  be  controlled  by 
the  general  principle  that  further  irritation  of  any  already 
inflamed  joint  should  be  avoided.  The  chief  exception  to  this 
is  to  be  seen  when  it  becomes  necessary  in  the  course  of  a 
chronic  but  quiescent  arthropathy  to  attempt  gradual  exten- 
sion of  motion  in  a  stiffened  joint.  When  the  associated  ten- 
dons have  been  the  seat  of  a  fibrositis,  and  through  disuse 
have  become  shortened,  it  is  obviously  necessary  that  they 
should  be  stretched  before  the  muscles  opposing  them  can 
regain  function.  In  accomplishing  this  a  certain  degree  of 
irritation  and  pain  is  unavoidable,  but  this  should  rarely  be 
induced  until  the  arthritis  proper  has  subsided.  One  other 
exception  to  the  above-mentioned  principle  is  to  be  seen  in 
those  cases  which  are  progressive  from  bad  to  worse  despite 
all  efiforts  to  the  contrary.  In  them  a  moderate  degree  of 
irritation  is  justifiable,  if  it  retains  existing  function.  Every 
effort  must  be  made  under  these  circumstances  to  postpone 


INFECTIOUS    ARTHRITIS.  557 

the  immobilization  of  joints  which  will  eventually  supervene, 
despite  treatment. 

Massage  itself  does  not  necessarily  involve  any  movement 
of  the  joints,  and  yet,  unless  care  can  be  exercised,  they  may 
be  incidentally  disturbed,  and  so  be  made  to  suffer  by  its  use. 
Its  most  important  function  is  found  in  those  instances  where 
it  becomes  necessary  to  restore  atrophied  muscles  to  function- 
ating- capacity.  Sooner  or  later  in  nearly  all  chronic  cases  of 
arthritis  there  is  more  or  less  sparing  of  the  joint,  and  hence  of 
the  muscles  which  move  the  joint.  As  a  result  of  this,  atrophy 
of  disuse  follows  in  some  degree,  and,  indeed,  may  go  on  to 
nearly  complete  loss  of  function.  It  is  perhaps  not  often 
appreciated  by  those  in  charge  of  such  cases  that  part  of  the 
difficulty  experienced  by  patients  in  moving  a  chronically 
painful  joint  arises  from  the  fact  that  great  overaction  of  the 
reduced  muscle  substance  becomes  necessary.  This  results  in 
irregular  and  explosive  effort  to  move  the  joint,  which  in  itself 
introduces  painfvd  factors.  Furthermore,  the  muscle  often 
shares  in  the  systemic  processes  causing  the  arthritis,  and  may 
itself  be  the  subject  of  myositis. 

The  relative  violence  of  such  muscular  eft'ort  is  the  greater 
in  wasted  muscles,  so  that  it  is  important  that  the  muscle 
volume  and  tone  be  restored  as  nearly  as  possible.  Massage 
can  accomplish  a  great  deal  in  this  connection  if  begun  very 
gradually  and  continued  cautiously,  increasing  only  as  the 
patient  is  able  to  stand  it.  Furthermore,  if  the  muscles  be  not 
too  painful  to  tolerate  it,  massage,  in  a  sense,  may  take  the 
place  of  exercise,  and  contribute  toward  improving  the  local 
muscular,  as  well  as  the  systemic,  metabolism.  This  effect 
upon  the  systemic  metabolism  is  very  real,  and  should  be 
utilized  in  every  case  where  the  circumstances  of  the  patient 
warrant  it,  and  it  is  not  too  painful  a  process  for  him  to 
undergo  with  comfort.  It  is  to  be  borne  in  mind,  however, 
that,  together  with  exercise,  it  makes  a  demand  upon  the  body 
as  a  whole,  and  the  physician  in  charge  should  see  that  the 
food  intake  of  the  patient,  together  with  the  period  of  rest 
allowed  for  recuperation  after  massage,  is  quite  adequate  to 
the  individual  case. 

,  The  use  of  rest  in  the  treatment  of  the  arthritides  needs 
some  emphasis.    There  are  some  instances  in  which  the  con- 


558        DISEASES    OF   METABOLISM   AND    NUTRITION. 

tinued  normal  function  of  a  part  may  perpetuate  locally  the 
symptoms  of  an  arthritis  which  has  elsewhere  subsided.  Par- 
ticularly is  this  true  of  the  weight-bearing  parts,  such  as  the 
foot,  knees,  hips  and  sacroiliac  joints.  In  subsiding  arthritides 
of  the  hand,  for  example,  knitting  may  serve  to  introduce 
mechanical  irritation  of  joints  already  the  seat  of  an  inflam- 
matory process.  In  nearly  all  cases,  whatever  the  distribution 
of  the  arthritis,  rest  will  achieve  some  benefit,  if  it  follows 
upon  a  period  of  more  or  less  activity,  and,  within  limits,  it 
can  nearly  always  be  profitably  advised.  On  the  other  hand, 
it  should  rarely  be  carried  to  the  point  of  adding  to  the  atrophy 
of  disuse,  which  is  so  prone  to  follow  upon  a  chronic  arthritis, 
and,  furthermore,  if  too  long  persisted  in,  unnecessary  limita- 
tion of  motion,  or  even  partial  ankylosis,  may  ensue. 

When  the  sacroiliac  joints  are  the  seat  of  an  arthritis,  par- 
ticular care  is  necessary  to  differentiate  the  possible  and  the 
actual  operative  factors.  Only  when  these  have  been  clearly 
analyzed  can  treatment  be  intelligently  directed,  and  there  is 
probably  more  confusion  of  diagnosis  here  between  the  infec- 
tious or  other  arthritides  and  the  mechanical  types  due  to  sub- 
luxation than  in  any  other  joints. 

As  a  purely  practical  measure  attention  must  be  drawn  to 
the  importance  of  flat-foot  as  a  contributory  factor  in  cases  of 
arthritis  involving  joints  below  the  waist.  Discussion  of  the 
true  static  arthropathies  has  no  place  here,  but,  in  conjunction 
with  the  varieties  of  arthritis  mentioned,  flat-foot  and  the  im- 
proper distribution  of  the.  body  weight  play  a  role.  The  feet 
should  be  critically  examined  in  all  cases,  and  it  is  noteworthy 
that  the  true  infectious  arthritides  of  the  feet  can  be  very 
closely  simulated.  This  influence  must  be  eliminated  as  a 
factor  or  corrected.  Prolonged  rest,  strapping  of  the  feet, 
casts  to  hold  the  feet  in  proper  position,  exercises,  correct  sup- 
port of  the  arch,  advanced  and  raised  heels,  and  shoes  made 
on  a  proper  last,  may  all  be  useful  in  meeting  the  necessities. 
Their  institution  should  preferably  be  supervised  by  an  ortho- 
pedist, though  the  possible  factor  which  flat-foot  plays  here 
sometimes  escapes  even  the  specialist. 

Local  medicinal  application  to  the  joints  is  confined  to  a 
very  few  measures  which  have  demonstrated  value.  Hot,  cold, 
or  counterirritant  applications   of   any   kind   may  give   tern- 


PRIMARY    PROGRESSIVE    POLYARTHRITIS.  559 

porary  subjective  relief,  and  are,  of  course,  entirely  harmless. 
The  well-known  counterirritants  of  the  pharmacopoeia  can,  of 
course,  be  applied,  but  the  most  useful  measures  in  this  con- 
nection are  perhaps  methyl-salicylate  ointment  and  mesotan 
ointment,  the  latter  in  strength  of  10  to  25  per  cent.  Care 
should  be  exercised  that  no  undue  irritation  of  the  skin  be 
produced  by  overapplication  of  these  drug's.  Wrapping  the 
joint  in  gauze  soaked  with  a  saturated  solution  of  magnesium 
sulphate  may  relieve  pain  considerably. 

Climate  needs  little  mention  beyond  the  fact  that  subjects 
of  arthritis  do  better  in  general  in  a  dry  and  warm  climate 
than  in  cold  and  damp  localities.  Abrupt  changes  in  weather 
conditions  often  cause  added  discomfort  to  these  sufferers. 

PRIMARY    PROGRESSIVE    POLYARTHRITIS. 

Finally  we  come  to  the  last  important  group  of  arthritides 
which  deserve  consideration  here,  this  being  the  so-called 
primary  progressive  polyarthritis,  the  fourth  group  in  the 
classification  adopted.  Opinions  dififer  as  to  whether  this  is 
really  a  distinct  entity  in  itself,  or  whether  it  is  properly  a 
variety  of  the  preceding  secondary  chronic  infectious  type  of 
arthritis.  However  this  may  be  the  etiology  is  by  no  means 
so  clear  as  in  the  case  of  the  infectious  type,  and  consequently 
treatment  has  been  proportionately  difficult  and  less  suc- 
cessful. 

The  pathology  of  this  group  does  not  differ  radically  from 
that  last  described.  The  disease  may  arise  insidiously  with 
fever  and  periarticular  swelling  of  the  smaller  joints,  or  it  may 
be  characterized  rather  by  an  increasing  stiffness  and  pain 
with  less  implication  of  the  soft  tissues.  In  both  instances  it 
becomes  eventually  diffuse,  and  more  or  less  symmetric.  The 
first  of  these  two  varieties  is  sometimes  called  the  exudative 
type,  the  latter  the  so-called  dry  form. 

There  is  no  way  of  ascertaining  clearly  when  a  case  is  first 
seen  that  it  belongs  in  this  general  group,  because  the  possi- 
bility of  an  infectious  origin  cannot  l)e  dismissed  until  it  is 
proved  not  to  exist  by  means  of  the  careful  measures  outlined 
above.  When  every  step  has  l)een  taken,  however,  and  every 
possible  source  of  infection  has  been  removed,  and  the  patient 


560        DISEASES    OF   METABOLISM    AND    NUTRITION. 

still  fails  to  respond  in  the  manner  desired,  it  may  justly  be 
suspected  that  the  case  is  one  of  this  refractory  type.  Again, 
there  is  a  certain  proportion  of  cases  in  which  no  infection  can 
be  .found  which  also,  obviously,  belongs  in  the  same  category. 
This  class  calls  for  the  most  patient  and  thorough  care  on  the 
part  of  the  physician,  and  it  is  precisely  in  this  type  of  case 
that  the  various  adjuvants  of  baking,  mineral  waters,  baths, 
and  the  host  of  other  measures  recommended  have  been  most 
freely  advised. 

In  these  cases  are  found  most  frequently  the  elongation 
and  tortuosity  of  the  large  bowel,  together  with  stasis  and 
great  delay  in  the  passage  of  the  bismuth  test-meal,  mentioned 
under  treatment  of  the  infectious  arthritides.  Even  more  im- 
portantly than  in  the  last-mentioned  group  should  this  condi- 
tion call  for  correction,  and  the  measures  there  outlined  should 
be  given  careful  consideration.  The  radical  operations  advised 
by  Lane  and  his  followers  have  here  the  excuse  which  comes 
nearest  to  justifying  them  as  an  established  procedure. 

Radium  emanation  has  recently  come  into  the  foreground 
as  a  therapeutic  agent  in  this  disease,  but  it  is  as  yet  too  soon 
accurately  to  outline  its  limitations  for  good  and  evil.  It  is 
clear,  however,  that,  as  indicated  in  connection  with  measures 
such  as  arsenic,  .r-ray  and  thyroid  extract,  it  importantly 
influences  metabolism  at  large.  Its  effect  in  this  connection 
is  comparable  to  that  of  the  jr-ray.  Among  the  various  actions 
attributed  to  radium  emanation  are  those  of  "energizing  the 
body  ferments"  or  enzymes,  and  increasing  tissue  oxidation. 
Speculation  is  unprofitable  here,  but  it  seems  clear  that  clinical 
results  which  follow  its  use  can  best  be  explained  upon  the 
above  hypothesis.  Its  therapeutic  use,  however,  is  essentially 
limited  to  those  cases  where  the  effects  of  heightened  metab- 
olism within  the  tissue-cells  are  sufficient  to  meet  the  constant 
access  of  toxic  matter  to  the  cells;  at  least,  this  seems  to  be 
the  case.  The  use  of  the  commercial  preparations  of  radium 
emanation,  for  which  somewhat  extravagant  claims  have  been 
put  forward,  has  met  with  little  real  success.  In  skilled  hands 
treatment  by  this  powerful  agent  has  some  value  in  these 
conditions,  but  in  general  benefits  from  this  source  are  best 
sought  at  the  various  "Kurorts"  of  Europe  and  elsewhere, 
where  they  are  heightened  by  the  regime  of  life  instituted  at 


PRIMARY    PROGRESSIVE    POLYARTHRITIS.  561 

such  places.  In  the  report  of  the  work  carried  out  at  the 
Radium  Institute,  London,  1914^8  it  is  stated  that  the  daily 
administration  of  250  c.  en.  of  radium  emanation  sohition 
of  a  strength  of  not  less  than  1  milHcurie  per  Hter  is 
sometimes  productive  of  very  remarkable  results.  The 
degree  of  improvement  is  hard  to  predict  with  certainty,  but 
the  cases  which  appear  to  derive  most  benefit  are  those  in 
which  the  disease  is  of  relatively  short  duration,  and  the 
changes  are  periarticular  in  type  and  polyarticular  in  distrib- 
ution. At  least  six  weeks  are  likely  to  elapse  after  the  institu- 
tion of  treatment  before  any  change  is  noted.  The  whole  topic 
of  radium  therapy  is  so  little  developed  that  dogmatism  at 
this  stage  is  to  be  discountenanced,  and  unless  the  subject  be 
approached  through  the  legitimate  and  scientific  channels  of 
those  working  in  it,  it  were  probably  best  left  alone. 

For  some  years  the  writer  has  made  the  general  group  of 
arthritides  now  under  consideration  the  subject  of  a  study, 
which  has  resulted  in  measures  capable,  at  times,  of  very  real 
benefit.  These  studies  are  not  yet  complete,  and  conclusions 
based  on  them  are  therefore  subject  to  later  modification,  but 
in  view  of  the  definite  benefits  observed  it  seems  proper  to 
include  here  such  references  to  the  method  as  will  at  least 
allow  an  understanding  of  the  principle  concerned,  and  the 
general  manner  in  which  it  should  be  applied.  For  full  details 
the  reader  must  be  referred  to  the  original  articles  on  the  sub- 
ject.89  It  is  not  entirely  clear  that  this  general  type  alone 
has  yielded  to  the  treatment  to  be  described,  and,  on  the  other 
hand,  there  is  some  reason  to  regard  the  second  subvariety  of 
it,  called  the  dry  form  of  primary  progressive  pol3^arthritis,  as 
possibly  more  refractory,  but  for  convenience  of  discussion 
the  question  at  large  can  be  taken  up  here,  since  for  this 
general  type  of  arthritis  no  other  specific  therapy  has  been 
advanced.  Indeed,  when  every  possible  focus  of  infection  has 
been  removed  in  any  thoroughly  studied  case,  and  the  patient 
still  remains  the  subject  of  an  active  arthritis,  these  measures 
can  be  properly  considered.  In  explanation  of  this  method  of 
treatment  a  few  preliminary  remarks  are  necessary.  It  has 
been  observed,  in  individuals  the  subject  of  rheumatoid  arth- 
ritis who  have  undergone  a  major  operation,  that  following 

36 


562        DISEASES    OF   METABOLISM    AND    NUTRITION. 

the  operation  there  is  often  a  period  of  subjective  relief,  li 
has  long-  been  known  that  agents  that  profoundly  influence 
the  body  metabolism,  such  as  arsenic,  thyroid  extract,  and  th^ 
jT-ray,  sometimes  have  a  temporary  beneficial  effect  upon  the 
objective  as  well  as  the  subjective  symptoms  of  the  disease. 
It  has  seemed,  from  a  correlation  of  these  facts,  that  this 
benefit  following  operation  might  be  due  to  institution  of  the 
so-called  basal  metabolism,  ^.pproximated  in  the  period  of  star- 
vation which  follows  many  abdominal  operations.  It  was 
conceivable  that  under  these  conditions  the  body  might  be 
spared  the  utilization  of  the  food  intake,  and  that,  at  the  same 
time,  having  less  to  do,  the  tissue-cells  most  concerned  in 
these  processes  would  be  able  better  to  perform  their  work. 
This  hypothesis  was  in  harmony  with  the  beneficial  effects  in 
this  disease  of  arsenic,  the  A'-ray,  radium,  exercise,  and  other 
agents  which  operate  in  the  opposite  connection;  namely,  to 
hasten  catabolic  processes,  and,  possibly,  anabolic  processes 
as  well,  and,  so  to  speak,  "whip  the  flagging  horse." 

If  these  facts  were  true,  it  seemed  possible  that  there 
might  be  a  midpoint  at  which  the  subject  of  arthritis  could 
utilize  a  lowered  intake  of  food  with  satisfaction  to  his  nutri- 
tive needs,  and,  at  the  same  time,  without  injury  to  the  joints, 
as  expressed  by  the  arthritis.  The  general  correctness  of  this 
hypothesis  has  been  indicated  by  work  based  upon  it. 

Apparently  there  exists,  in  many  cases  of  this  general  type 
of  arthritis,  a  level  of  intake  of  carbohydrate  and  protein  food 
above  which  the  individual  is  ill,  and  below  which  improve- 
ment or  entire  convalescence  may  follow.  This  level  varies 
with  the  individual  case,  and  no  set  rule  can  be  given  for 
ascertaining  it,  though  it  is  generally  below  the  average  intake 
of  either;  often  very  much  so. 

Experiments  in  connection  with  fat  indicate  that,  althoiUtgh 
it  is  rarely  possible  to  replace  the  curtailed  caloric  witake- 
entirely  by  fat,  it  is  often  possible  to  give  part  of  thi:?  in  the^ 
form  of  fat  without  injury  to  the  arthritis,  and  with  benefit  to, 
the  nutritive  needs.* 


*  Since  the  'above  was  written  it  has  been  found  possible  to.  carry- 
through  to  convalescence  two  chronic  cases  who  were  made  to  gain  weight 
by  the  use  of  large  quantities  of  fat  which  entirely  replaced  the  caloric 
deficit. 


PRIMARY   PROGRESSIVE    POLYARTHRITIS.  563 

In  brief,  the  facts  seem  to  be  that  in  treating  cases  along 
these  Hnes  it  is  necessary  to  reduce  the  carbohydrates  by  an 
important  amount,  varying  with  each  case ;  that  it  is  neces- 
sary to  reduce  the  proteins  considerably,  but  relatively  not  so 
much;  and,  finally  that,  although  the  fats  cannot  be  handled 
with  impunity,  they  may  be  used  with  caution  to  increase  the 
caloric  value  of  the  ingested  food,  and  meet,  in  some  degree 
or  altogether,  the  loss  of  weight. 

It  is  entirely  conceivable  that  the  role  played  by  the  food- 
stuffs depends  upon  bacterial  activity  in  the  intestinal  tract. 
It  seems  likely  at  present  that  at  least  some  of  the  substances 
causing  the  damage  arise  in  the  cleavage  of  the  carbohydrate 
and  protein  molecule,  either  bacterially  within  the  intestines 
or  physiologically  from  enzyme  action,  and  that  an  important 
phase  of  the  disease  concerns  the  ability  or  inability  of  the 
tissue-cells,  particularly  perhaps  in  the  muscles,  to  utilize  and 
to  destroy  these  midproducts.  Whatever  the  real  method  of 
action,  the  fact  is  that  reduction  of  the  carbohydrate  and  pro- 
tein reduces  the  sum-total  of  injurious  matter  which  reaches 
the  tissues. 

In  undertaking  the  treatment  of  a  case  it  is  the  writer's 
practice  to  observe  the  individual  for  a  few  days,  during  which 
a  record  is  kept  of  the  entire  food-intake  in  terms  of  grams 
and  mils.  This  can  readily  be  done  by  any  nurse  trained  in 
modern  methods,  and  requires  nothing  more  than  a  measure 
and  a  pair  of  scales  weighing  to  1  gram.  Some  intelligent 
patients  have  conducted  this  alone.  From  this  record  a  pretty 
close  idea  can  be  obtained  as  to  what  the  individual  normally 
ingests,  and  about  the  number  of  calories  required  to  keep 
him  in  equilibrium.  During  this  probationary  period  he  is 
urged  to  live  nearly  as  possible  according  to  his  usual  habits, 
with  relation  to  exercise  and  general  activity. 

It  is  well  to  have  the  ingredients  of  the  probationary  diet 
prepared  according  to  some  definite  formulary.  A  very  use- 
ful one  is  to  be  found  in  a  small  book  entitled  "Food 
Values,"^^  in  which  are  set  forth  nearly  all  the  useful  table 
articles,  with  their  caloric  value  appended. 

From  the  record  of  the  individual's  intake  of  food,  the 
average  daily  caloric  intake  can  be  fairly  closely  approxi- 
mated.    Since  the  symptoms  of  disease  have  persisted  in  gen- 


564       DISEASES   OF   METABOLISM   AND   NUTRITION. 

eral  under  these  conditions,  it  follows  that  any  method  of 
treatment  which  involves  a  curtailment  of  food  must  reduce 
the  food-intake  to  a  point  at  least  below  the  average  which 
has  been  ascertained. 

Furthermore,  it  is  of  prime  importance  that  the  nutritive 
needs  of  the  body  be  met  or  kept  well  in  mind,  and  in  making 
reductions  as  severe  as  those  sometimes  entailed  here  it  is 
important  that  no  harm  be  done  to  the  individual.  One  can 
be  sure  of  this  only  if  the  actual  caloric  value  of  the  intake 
ordered  is  known.  It  is  important  to  give  as  much  food  as 
the  subject  can  tolerate  without  injury  to  his  joint-structures, 
from  which  it  follows,  in  the  writer's  experience,  that  diets 
have  had  to  undergo  several  changes,  the  first,  or  even  the 
second,  being  too  ample  to  achieve  the  results  desired;  but 
as  it  is  impossible  to  determine  beforehand  what  that  amount 
will  be,  it  is  well  to  proceed  cautiously  in  the  above  manner, 
especially  as  some  few  cases  of  long  standing  and  apparently 
severe  arthritis  manifest  striking  improvement  upon  relatively 
slight  modifications  in  their  diet. 

It  may  be  said  that  a  recent  case  in  a  young  subject 
requires  in  general  a  slight  modification,  as  compared  with 
an  advanced  case  of  long  standing,  and  if  the- average  normal 
food-intake  be  found  high,  it  may  be  assumed  with  fair  prob- 
ability that  the  new  diet  need  not  be  very  restricted.  On  the 
other  hand,  if  the  average  food-intake  be  found  low,  it  is 
obviously  necessary  to  strike  an  even  lower  level.  For  exam- 
ple, in  patients  living  upon  a  caloric  intake  of  3500  calories 
there  is  a  very  good  chance  that  a  reduction  of  this  amount 
to,  say,  2500  calories,  will  still  leave  them  ample  for  all  rea- 
sonable nutritive  needs,  and  at  the  same  time  relieve  them  of 
a  surplus  of  food  amounting  to  1000  calories.  On  the  other 
hand,  if  the  individual  be  ingesting  normally  only  1900  calor- 
ies, as  sometimes  occurs  in  the  secondary  invalidism  of  this 
disease,  it  is  plain  that  no  such  reduction  can  be  made.  It  is 
necessary  then,  however,  to  strike  an  even  lower  level  of,  say, 
1500  or  even  1200  calories,  and  so  on.  There  is  obviously  a 
limit  to  which  this  can  be  carried,  except  for  short  periods. 
The  use  of  calories  in  this  connection  is,  of  course,  simply  as 
a  measure  of  amounts  of  food,  and  has  no  necessary  relation 
to  the  study  of  calorimetry  of  the  body  in  general.     In  draw- 


PRIMARY    PROGRESSIVE    POLYARTHRITIS.  565 

ing  up  a  new  dietary  the  protein  and  carbohydrates  are  the 
chief  factors  to  be  considered,  and  the  caloric  value  decided 
upon  must  begin  with  the  calories  from  these  sources.  Cer- 
tain other  factors  are  also  important,  however.  For  example, 
there  are  many  articles  of  diet  whose  bulk  is  considerable  for 
the  food-value  contained,  such  as  apples,  tomatoes,  spinach, 
celery,  beets,  cabbage,  turnips  and  lettuce,  which  are  exceed- 
ingly useful  to  take  the  edge  ofif  the  appetite  and  to  serve  as 
a  basis  for  the  really  nutritive,  but  restricted  articles  which 
follow  in  the  form  of  bread,  eggs  and  meat. 

It  is  immaterial  how  the  carbohydrates  and  proteins  be 
administered  within  the  given  amounts  determined  upon, 
though  a  nearly  exact  estimation  is  easier  if  they  be  simply 
prepared.  Until  convalescence  is  well  underway,  it  is  best  to 
adhere  to  the  simple  staples,  such  as  bread,  butter,  sugar,  milk, 
roast,  broiled  or  boiled  meat  and  fish,  rice,  boiled  or  roasted 
potatoes,  etc.  No  one  diet  can  be  chosen  that  is  suitable  for 
all  cases,  for  the  reasons  given  above,  but  as  an  illustration 
the  following  may  be  cited  as  a  dietary  suitable  to  a  mild  type 
of  case.  It  must  be  emphasized,  that  no  one  diet  will  suit 
every  case : 

Breakfast:  Calories. 

1   apple    ISO  Gms.  72 

1    egg    50  Gms.  83 

1   slice  bread    30  Gms.  81 

Butter    10  Gms.  80 

Weak  coffee  and 

20  per  cent,  cream,  1  tablespoon ful  ...   15  mils  54 

Sugar  1  teaspoonful    7  Gms.  28 

11  A.M. : 
Olive  oil,  1  tablespoonful    15  mils  121 

Lunchco)i: 

Vegetable  soup,  strained,   f§vj    180  mils  25 

Lettuce    q.  s. 

Mayonnaise,   1   tablespoonful    15  mils  187 

Spinach    50  Gms.  28 

Butter    5  Gms.  40 

1   orange    250  Gms.  96 

4  P.M. : 

Olive  oil,  1  tablespoonful   15  mils  121 


566        DISEASES    OF   METABOLISM    AND   NUTRITION. 

Supper:  Calories. 

1    apple    150  Gms.  72 

Weak  tea  and 

20  per  cent,  cream,  1  tablespoonful  ...   15  mils  54 

Sugar,  1  teaspoonful  7  Gms.  28 

Chicken  or  beef   50  Gms.  100 

Bread,   1   slice    30  Gms.  81 

Butter    10  Gms.  80 

Lettuce    q.  s. 

French  dressing,   1  tablespoonful   15  mils  148 

9  P.M.: 

Olive  oil,    1   tablespoonful    15  mils  121 

1700 

The  beneficial  influence  of  a  diet  cannot  always  be  pushed 
to  a  successful  conclusion  for  a  number  of  reasons :  for  exam- 
ple, in  the  presence  of  emaciation,  anemia,  advanced  heart 
disease,  and  the  like,  the  already  unstable  equilibrium  may  be 
further  upset  by  a  lowered  food-intake,  however  slight,  and 
this  may  then  be  strongly  contraindicated.  It  is,  of  course, 
of  the  highest  importance  that  individuals  should  be  put  at 
modified  or  complete  rest  coincidently  with  a  moderate  or 
severe  curtailment  of  their  energy  intake,  and  this  important 
essential  cannot  be  emphasized  too  strongly.  The  weight  also 
must  be  watched  daily. 

Patients  often  need  encouragement  during  the  long  period 
required  for  treatment,  since  they  not  unnaturally  mistake  the 
secondary  results  of  arthritis  for  a  continuation  of  the  causa- 
tive arthritis,  although,  in  fact,  this  may  be  subsiding. 

It  must  not  be  supposed  that  all  cases  will  respond  equally 
well.  Wider  experience  may  develop  more  types  in  which  no 
response  can  be  detected,  but  it  is  safe  to  say  that  in  a  large 
number,  perhaps  in  a  majority,  of  cases  which  have  yielded  to 
no  other  measures,  definite  benefit  or  cure  can  be  seen.  The 
general  nutrition  of  the  individual  largely  determines  the 
degree  to  which  treatment  can  be  pushed,  and  in  every  case 
the  individual,  and  not  the  arthritis,  must  primarily  determine 
the  vigor  of  treatment.  It  is  of  small  benefit  to  improve  the 
arthritis  at  the  expense  of  the  patient's  health  as  a  whole. 
The  writer  cannot  emphasize  too  strongly  this  point,  for  any 
severe  dietary  procedure  is  a  two-edged  tool,  and  must  be  used 
with  the  greatest  possible  caution. 


PRIMARY    PROGRESSIVE    POLYARTHRITIS.  567 

In  undertaking-  treatment  along  these  lines  it  is  important 
to  determine  whether  arrest  of  the  disease  in  an  advanced  case 
would  justify  such  prolonged  sacrifice  as  must  be  made  to 
achieve  a  real  cure.  It  not  infrequently  happens  that  struc- 
tural deformity  is  so  far  advanced  and  muscular  atrophy  has 
become  so  chronic  that,  although  the  arthritis  were  to  be 
arrested  instanter,  there  would  still  remain  practically  as  much 
disability  and  pain  as  originally  noted.  It  is  as  true  of  treat- 
ment here  as  in  any  other  condition,  that  there  must  be  an 
intelligent  selection  of  those  cases  which  best  deserve  an 
effort.  In  relatively  young  persons  of  good  nutrition,  in  whom 
no  foci  of  infection  exist,  especially  if  they  be  not  very  far 
advanced,  the  most  vigorous  attempt  is  more  than  justified, 
and  it  is  precisely  in  this  class  that  the  most  significant  results 
can  be  seen. 

The  writer  has  found  codliver  oil  of  great  value  after 
response  to  treatment  has  been  clearly  evidenced,  and  the 
patient  has  settled  down  to  protracted  adherence  to  a  low 
diet.  Under  these  circumstances,  when  the  toxemia  has  been 
removed,  the  blood  may  rise  from  figures  of  anemia  to  those 
of  complete  normality. 

As  convalescence  proceeds,  it  is  often  possible  to  increase 
the  food-intake,  in  some  cases  vei-y  measurably,  so  that  the 
necessity  for  reduced  activity  may  grow  less  or  disappear,  and 
the  individual  may  be  allowed  to  resume  his  full  activities. 

Rheumatoid  Arthritis  or  Arthritis  Deformans.  The  condi- 
tion designated  by  these  names  is  classified  by  modern  nomen- 
clature under  Arthritis,  especially  of  the  infectious  type  and 
therefore  calls  for  no  separate  consideration,  as  the  above 
terms  are  merely  generic  synonyms. 

Myalgia.  Myalg^ia  may  be  defined  as  a  condition  in  which 
there  is  pain  in  the  muscles.  Outside  of  such  causes  as  trau- 
matism and  the  like  it  may  be  regarded  as  referable  to  the 
conditions  which  form  the  underl3nng  basis  of  arthritis  in 
general.  In  other  words,  in  arthritis  of  the  infectious  and 
"metabolic"  types  the  nerves  and  muscles  may  be  affected  as 
well  as  the  joint  structures  per  se,  constituting  the  condition 
commonly  referred  to  as  mj^algia. 

The  condition  within  the  muscles  is  regarded  by  Llewellyn 
Jones  (see  Arthritis,  p.  544)   as  of  the  nature  of  a  fibrositis, 


568        DISEASES    OF    METABOLISM    AND    NUTRITION. 

The  muscle  may  show  nothing  abnormal  to  inspection  or 
palpation  except  tenderness.  On  the  other  hand,  a  sense  of 
resistance  and  rigidity  may  be  detected.  Pressure,  passive 
motion,  and  active  motion  may  be  exceedingly  painful.  Any 
of  the  muscles  of  the  body  may  be  attacked,  although  perhaps 
those  most  frequently  affected  are  in  the  lumbar  region,  the 
upper  arm,  and  the  shoulder. 

The  treatment  of  this  condition  depends  upon  recognition 
of  the  underlying  cause  and  the  institution  of  steps  to  remove 
it.  The  cause  may  be  purely  infectious,  as  in  a  decayed  tooth 
or  an  inflamed  tonsil.  If  every  possible  infectious  focus  is 
removed  from  consideration  the  cause  may  be  conceivably 
regarded  as  "metabolic,"  in  the  sense  described  under  Primary 
Progressive  Polyarthritis.  Under  these  circumstances  treat- 
ment can  be  instituted  along  the  lines  mentioned  under  this 
topic  (see  p.  559). 

Local  therapy  has  a  place  in  myalgia,  and  in  cases  of 
trifling  severity  is  often  sufficient  to  dissipate  it.  Massage 
may  be  agreeable,  if  it  does  not  cause  too  much  pain,  but  it 
should  be  governed  by  the  same  principles  which  govern 
massage  of  the  joints.  Heating,  baking,  and  the  well-known 
counter-irritants  are  entirely  admissible,  and  the  salicylates 
by  mouth  are  often  of  great  avail. 

In  general  the  subject  of  myalgia  should  be  regarded  as 
forming  one  of  the  manifestations  of  the  causes  producing 
arthritis,  and  so  treated. 

CHRONIC    VILLOUS    ARTHRITIS. 

The  villous  arthritis  of  Goldthwait  probably  is  a  purely 
static  type  often  referable  to  flat-foot,  for  example,  and  needs 
no  particular  emphasis  here  other  than  that  sufficient  to  direct 
attention  to  removing  this  possible  cause.  It  is  characterized 
by  an  absence  of  general  symptoms,  by  crepitation,  and  by 
varying  degrees  of  pain  upon  movement. 

CHRONIC   ARTHROPATHIES    OF   THE    SPINE. 

The  spinal  types  of  arthropathy  do  not  differ  in  principle 
from  the  infectious  and  primary  progressive  varieties,  and  are 
characterized  by  the  imprint  of  the  disease  upon  the  spine 


HEBERDEN'S    NODES.  569 

rather  than  upon  other  structures.  The  vertebral  column  is 
subject  to  the  same  morbid  process  which  affects  the  other 
joints,  and  for  purposes  of  treatment  it  seems  unimportant  to 
differentiate  the  pathologic  variations  encountered. 

It  is  sufficient  that  attention  be  given  most  critically  to  the 
discovery  of  possible  etiologic  factors  in  the  way  of  infection, 
and  when  this  fails  of  results  the  treatment  must  depend  upon 
the  general  principles  already  described.  Under  these  circum- 
stances the  influence  of  diet  as  outlined  under  the  fourth  group 
of  primary  chronic  progressive  polyarthritis  may  be  very  real. 
It  is  possible,  however,  since  the  natural  range  of  motion  of 
the  vertebral  articulations  is  slight,  that  conditions  approach- 
ing ankylosis  may  supervene  sooner  in  the  spine  than  else- 
where, and  treatment  should  be  instituted  proportionately 
early. 

STILL'S    DISEASE. 

The  general  principles  which  underlie  the  consideration 
and  treatment  of  the  above  arthritides  apply  to  Still's  disease, 
so  called ;  and  in  this  condition  every  effort  should  be  made 
to  ascertain  the  etiologic  factors  at  stake.  In  certain  features, 
such  as  the  glandular  and  splenic  enlargements,  it  differs 
from  the  diffuse  arthritides  of  adults,  but  the  pictures  of  the 
adult  and  juvenile  forms  of  arthritis  may  closely  resemble  each 
other.  Except  for  the  limitations  which  childhood  places  upon 
all  therapeutic  measures  there  is  but  little  reason  to  particu- 
larize in  regard  to  treatment  of  this  condition.  Restrictions  of 
diet  in  general  are  not  advisable,  owing  to  the  necessities  for 
growth.  The  paramount  importance  to  the  child  of  good 
hygiene  and  good  food  must  be  kept  prominently  in  mind. 
Mutch  has  laid  emphasis^i  upon  the  role  of  the  Staphylo- 
coccus citreus  within  the  intestine  and  in  the  circulating  blood 
as  the  cause  of  Still's  disease,  and  advocates  the  radical  pro- 
cedures of  ileocolostomy  and  colectomy  as  the  only  measures 
of  value. 

HEBERDEN'S    NODES. 

Attention  has  long  been  directed  to  the  articular  deformi- 
ties known  as  Heberden's  nodes,  but  it  is  very  questionable 
whether   they    deserve    any    particularization.      Indeed    they 


570        DISEASES    OF   METABOLISM   AND    NUTRITION. 

seem  to  be  merely  local  expressions  of  the  overgrowth  seen 
in  a  variety  of  arthritides  that  affect  the  smaller  joints  of  the 
hand.  Their  presence  means  the  existence  at  some  time  of 
the  underlying  factors  which  produce  infectious  or  primary 
arthritis. 

Not  infrequently  a  bursa  may  be  the  seat  of  pain  and 
swelling,  and  under  these  conditions  it  seems  clear  that  its 
synovial  lining  suffers  from  the  diffuse  process  attacking  other 
structures.  Subsidence  of  this  swelling  takes  place  as  the 
cause  of  the  general  morbid  process  is  removed. 

SUBCUTANEOUS    FIBROID    NODULES. 

Subcutaneous  fibrous  nodules  are  not  infrequently  met 
with  in  the  course  of  an  arthritis,  and  may  respond  by  sub- 
sidence to  the  institution  of  measures  which  benefit  the  arth- 
ritis proper. 

This  has  been  the  cause  to  a  noteworthy  degree  in  some 
instances  treated  by  the  writer  along  the  dietary  lines  dis- 
cussed under  primary  chronic  progressive  polyarthritis. 

Frequently  neuritis  is  an  accompanying  feature  of  arth- 
ritis, and,  indeed,  alone  may  be  an  expression  of  the  underly- 
ing factors  which  in  other  cases  lead  to  disturbances  in  the 
joints.  It  tends  to  improve  as  the  cause  is  removed.  It  is 
probable  that  a  not  inconsiderable  number  of  cases  of  sciatica 
have  a  similar  pathologic  basis. 


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41.  Gartner,  G. :     Reducing  Weight  Comfortably,  Philadelphia,  1914. 

42.  Bergonie,  B.  B.  Vincent:  Lyon  Internat.  Clinics  (S.  26),  1916, 
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45.  Roberts  and  Bradford :  Allbutt  and  Rolleston's  System  of  Medi- 
cine, Ed.  2,  London,  1907,  iii,  123. 

46.  Roberts  and  Bradford :  Allbutt  and  Rolleston's  System  of  Medi- 
cine, Ed.  2,  London,  1907,  iii,  104. 

47.  Pratt,  J.  H. :     Am.  Jour.  Med.  Sc,  1916,  cli,  92. 

48.  Hall,  I.  W. :     Purin  Bodies  of  Foodstuffs,  Ed.  2,  Philadelphia,  1904. 

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Berlin,  1913,  i,  149. 

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Berlin,  1913,  i,  230. 

51.  Luff,  A.  P. :    Gout,  London,  Cassel,  1907,  256. 

52.  Nicolaier:    Deutsch.  Arch.  f.  Klin.  Med.,  1908,  xciii,  331. 

53.  Allen,  F.  M. :  Boston  Med.  and  Surg.  Jour.,  1915,  clxxii,  241 ;  New 
York  State  Jour,  of  Med.,  1915,  xv,  330 ;  Jour.  Am.  Med.  Assn.,  1916,  Ixvi, 
525;  Am.  Jour.  Med.  Sc,  1916,  cl,  480;  Arch.  Int.  Med.,  1916,  xvii,  1010; 
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54.  Von  Noorden :     Abstr.  Jour.  Am.  Med.  Assn.,  1916,  Ixvii,  1556. 

55.  Janney:  Glucose  Formation  from  Proteins,  Arch.  Int.  Med.,  1916, 
xviii,  591. 

56.  Marriott :    Jour.  Am.  Ad:ed.  Assn.,  1916,  Ixvi,  1594. 

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59.  Riesman:     Am.  Jour.  Med.  Sc,  cli,  40. 

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1916,  cli,  313. 

61.  Joslin,  E.  P. :     Treatment  of  Diabetes,  Philadelphia,  1916. 

62.  Saundby :  Allbutt  and  Rolleston's  System  of  Medicine,  Ed.  2,  Lon- 
don, 1902,  iii,  167. 

63.  Joslin,  E.  P. :  Pregnancy  and  Diabetes  Mellitus,  Boston  Med. 
and  Surg.  Jour.,  1916,  clxxiii,  841. 

64.  Janeway,  T.  C. :  The  Dietetic  Treatment  of  Diabetes,  Am.  Jour. 
Med.  Sc,  1909,  cxxxvii   (new  series),  313. 

65.  Knerr:    Jour.  Am.  Med.  Assn.,  1916,  Ixviii,  929  (abstract). 

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York  State  Jour.  Med.,  1915,  xv,  330;  Jour.  Am.  Med.  Assn.,  1916,  Ixvi, 
1525;  Am.  Jour.  Med.  Sc,  1916,  cl,  480;  Arch.  Int.  Med.,  1916,  xvii,  1010. 

69.  Benedict,  S.  R. :    Jour.  Am.  Med.  Assn.,  1911,  ii,  1193. 


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1916. 

71.  Boston  Med.  and  Surg.  Jour.,  1915,  clxxxiii,  743. 

12.  Joslin,  E.  P. :  The  Treatment  of  Diabetes  Mellitus,  Philadelphia, 
1916. 

Ti.  Connecticut  Agricultural  Experiment  Station,  New  Haven,  Annual 
Report,  1913,  Part  1,  Sect.  1,  Diabetic  Foods. 

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and  McCrae:     Modern  Medicine,  Ed.  2,  Philadelphia,  1915,  721. 

75.  Cushing:     Boston  Med.  and  Surg.  Jour.,  1913,  clxviii,  901. 

76.  Miller :    Am.  Jour.  Med.  Sc,  1916,  clii,  549. 

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79.  Jones   (Llewellyn)   and  Jones   (A.  B.)  :     London,  1915. 

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81.  Billings,  F. :  Acute  and  Chronic  Rheumatism,  Jour.  Tennessee 
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84.  Lane,  Sir  Arbuthnot:  The  Operative  Treatment  of  Chronic  Intes- 
tinal Stasis,  Ed.  3,  London,  1915. 

85.  Smith,  Rea :  Ileocolostomy  and  Colectomy  for  Arthritis  Defor- 
mans, Jour.  Am.  Med.  Assn.,  1915,  Ixv,  771. 

86.  Miller,  Joseph  L.,  and  Lusk,  Frank  B. :  The  Treatment  of  Arthritis 
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Chronic  Joint  Disease ;  a  Preliminary  Report,  Am.  Jour.  Med.  Sc,  1912, 
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tinal Stasis,  Ed.  3,  London,  1915. 


Diseases  of  the  Nervous  System 

BY 

FRANCIS   X.    DERCUM,    A.M.,    M.D.,    Ph.D., 

Professor  of  Nervous  aaid  Mental  Diseases,  Jefferson  Medical  Col- 
lege, Philadelphia;  Ex-President  of  the  American  Neurological 
Association;  Foreign  Corresponding  Member  of  the  Neurological 
Society  of  Paris;  Corresponding  Member  of  the  Neurological  and 
Psychiatric  Society  of  Vienna;  Member  of  the  Royal  Medical 
Society  of  Budapest;  Consulting  Neurologist  to  the  Philadelphia 
General  Hospital,  etc., 

AND 

SHERMAN    F.    GILPIN,    M.D., 

Associate  in  Neurology,  Jefferson  Medical  College:  Chief  Clinical 
Assistant,  Outpatient  Nervous  Clinic,  Jefferson  Hospital;  Visiting 
Psychiatrist,   Philadelphia  General  Hospital. 


(575) 


Diseases  of  the  Nervous  System. 

FOREWORD. 

In  the  ensuing  Section  on  the  Treatment  of  Nervous  Dis- 
eases, the  authors  have  endeavored  to  lay  stress  upon  simple 
physiologic  procedures.  These  are  still  too  little  appreciated 
by  the  profession,  and  too  much  reliance  is  still  placed  upon 
the  giving  of  medicines.  The  importance  of  rest,  exercise, 
massage,  full  feeding,  careful  attention  to  the  digestive  tract 
and  the  various  organs  of  elimination  are  insisted  upon.  The 
importance  of  psychotherapeutics  is  pointed  out,  and  the  vari- 
ous methods  discussed  as  occasion  requires.  Finally,  when- 
ever medication  is  of  value,  .this  also  is  considered  in  detail. 


PART   I. 

FUNCTIONAL  DISEASES. 

Before  undertaking  the  treatment  of  a  given  disease,  we 
should  have  before  us,  whenever  possible,  clear  clinical  con- 
ceptions. This  is  especially  true  in  the  field  of  the  functional 
nervous  diseases,  and  we  will,  therefore,  first  briefly  review 
the  symptoms  of  the  various  affections  before  entering  into 
the  details  of  the  treatment.  Further,  inasmuch  as  neuras- 
thenia is  expressive  of  a  generalized  type  of  functional  nervous 
disorder,  it  will  be  given  a  rather  full  consideration.  Such  a 
course  leads  to  clear  and  direct  indications  for  treatment.  The 
latter,  as  we  will  see,  apply  also  to  a  number  of  other,  and  in 
a  sense  allied,  affections.  In  the  discussion  of  these,  the  gen- 
eral principles  indicated  in  the  study  of  neurasthenia  will  fre- 
quently be  referred  to. 

Among  the  various  generalized  neuroses  that  present  them- 
selves no  less  than  five  conditions  should  be  clinically  differ- 
entiated.   They  are  as  follows : 

^'  (577) 


578  DISEASES    OF   THE    NERVOUS    SYSTEM. 

Neurasthenia, 

Neurasthenoid  states,  or  psychasthenia, 
Neurasthenia  symptomatica, 
.   Hysteria,  and 
Hypochondria. 

NEURASTHENIA. 

This  affection  is  commonly  spoken  of  as  nervous  exhaus- 
tion, or  nervous  prostration.  The  symptoms  are  found  to 
depend  on  chronic  fatigue ;  and  Dercum  applied  to  it,  years 
ago,  the  term,  the  fatigue  neurosis.  Notwithstanding,  it  con- 
tinues to  be  much  misunderstood  by  many  physicians.  Thus, 
some  claim  that  nervous  exhaustion  is  rare  as  a  primary  affec- 
tion, that  it  is  always  secondary  to  some  other  disease,  such 
as  tuberculosis ;  that  it  is  the  result  of  some  condition  requir- 
ing surgical  interference,  or  that  it  occurs  only  in  those  pre- 
disposed from  birth  because  of  a  defective  physical  and  nerv- 
ous organization.  A  brief  consideration  will  soon  reveal  the 
erroneous!  character  of  these  views.  To  begin  with,  neuras- 
thenia may  present  itself  as  a  primary  state  of  persistent 
exhaustion,  and  may  occur  in  an  individual  otherwise  normal; 
or  it  may  occur  in  individuals  in  whom  there  is  a  more  or  less 
marked  hereditary  element,  i.e.,  a  neuropathic  constitution  or 
make-up,  and  in  which  the  symptoms  consequently  assume  a 
special  character.  The  condition  resulting  is  spoken  of  as  a 
neurasthenoid  state,  or,  to  employ  the  term  devised  by  Janet, 
as  a  psychasthenia.  Simple  or  uncomplicated  neurasthenia, 
i.e.,  nervous  exhaustion,  occurring  in  previously  healthy  per- 
sons, offers  an  exceedingly  favorable  prognosis.  The  neuras- 
thenoid states,  or  psychasthenias,  on  the  other  hand,  from  the 
very  fact  of  an  underlying  defective  nervous  system,  are  much 
less  promising,  although  in  many  cases  marked  improvement 
follows  the  application  of  general  physiologic  methods. 

Prominent  among  the  causes  of  neurasthenia  we  find  over- 
work, insufficient  rest  and  sleep,  mental  anxiety  and  worry, 
and  improper  nourishment  combined  with  the  excessive  use 
of  tea  and  coffee,  and  perhaps  alcohol.  We  are  not  all  born 
physically  or  mentally  equal;  we  cannot  all  be  athletes  physi- 


NEURASTHENIA.  579 

cally  or  giants  intellectually.  The  attempt  to  compel  the 
organism  to  do  more  work  than  it  was  ever  intended  to  do 
eventually  breaks  it  down  or  exhausts  it.  A  very  common 
cause,  especially  in  America,  is  the  constant  strain  and  habit- 
ual excess  of  work  imposed  by  the  high  pressure  of  business. 
Students  not  infrequently  break  down,  especially  at  the  close 
of  their  examinations.  Much,  too,  has  been  said  of  sexual 
excess.  Probably  the  drinking,  carousing  and  loss  of  sleep 
which  so  often  accompany  sexual  excess,  play  here  an  im- 
portant role.  Excessive  and  frequent  child-bearing  with  pro- 
longed lactation,  combined  with  overwork  or  worry,  is  also  a 
potent  cause.  Prolonged  nervous  exhaustion  likewise  at  times 
follows  infectious  diseases,  especially  influenza. 

The  essential  symptoms  of  neurasthenia  are  those  of  chronic 
fatigue,  and  are  classified  as  sensory,  motor,  psychic  and 
somatic. 

Sensory  Symptoms.  Among  sensory  s3^mptoms  the  patient 
presents  a  general  fatigue  sensation,  or  weariness,  which  is 
very  persistent.  It  is  one  of  the  primary  symptoms,  and  may 
dominate  the  picture  as  long  as  the  disease  exists.  Likewise 
the  patient  may  complain  of  being  dizzy  without  any  real  signs 
of  vertigo.  The  dizziness  is  probably  due  to  a  vasomotor 
weakness,  so  pronounced  that  slight  changes  of  position  affect 
the  intracranial  circulation. 

Localized  sensations  of  fatigue,  such  as  headache,  back- 
ache, or  limbache  are  frequent.  In  early  cases  they  disappear 
on  rest ;  in  long-standing  cases  they  may  only  be  relieved  if 
the  rest  be  long-continued.  The  headache  is  diffuse,  and  is 
usually  most  pronounced  in  the  occipital  region,  though  it 
may  be  frontal.  With  the  headache  we  frequently  have  asso- 
ciated sensations  of  pressure  or  constriction  of  the  head,  draw- 
ing sensations  in  the  back  of  the  head  and  neck ;  or  heaviness 
and  fullness  may  be  complained  of. 

The  backache  is  usually  referred  to  the  lumbar  region, 
sometimes  to  the  midscapular  region,  and  at  times  to  the 
sacrum  or  coccyx.  Like  the  headache,  the  backache  may  be 
regarded  as  a  fatigue  sensation.  Sometimes  the  back  becomes 
sensitive  to  touch,  or  there  may  be  tenderness  over  the  spine, 
limited  to  various  areas.  The  physicians  of  a  previous  gen- 
eration termed  this  symptom  "spinal  irritation."    Occasionally 


580  DISEASES    OF   THE    NERVOUS    SYSTEM. 

there  are  areas  of  tenderness  of  the  scalp,  gums,  or  teeth,  but 
never  the  localized  tender  spots  met  with  in  hysteria.  The 
aching'  of  a  particular  part  of  the  body  often  bears  a  distinct 
relation  to  the  occupation  of  the  patient,  and  the  overuse  of 
a  special  group  of  muscles;  for  instance,  aching  in  the  legs  of 
persons  who  stand  or  walk  a  great  deal,  or  aching  in  the  arms 
in  persons  with  occupations  in  which  the  arms  are  used  exces- 
sively. Loss  of  sensation — anesthesia — it  is  important  to  state, 
is  never  present,  though  the  patient  may  complain  of  numb- 
ness. Paresthesias,  such  as  tingling  or  sensations  of  heat  and 
cold,  may  also  be  complained  of. 

Symptoms  relating  to  the  eyes  are  frequently  present. 
These  may  consist  of  weakness  and  fatigue  of  the  eye  muscles 
or  irritability  of  the  retina.  Quite  commonly  they  are  accom- 
panied by  headache.  Because  of  the  underlying  exhaustion, 
refraction  of  the  eyes  usually  fails  to  relieve  either  the  ready 
fatigue  or  the  headache. 

Again,  the  patient  may  state  that  he  cannot  hear  well,  and 
that  he  frequently  fails  to  understand  what  is  said  to  him. 
The  fact,  however,  is  that  because  of  his  exhaustion  he  is 
unable  to  concentrate  his  attention.  True  deafness  does  not 
exist.  On  the  other  hand,  auditory  hyperesthesia  is  rather  a 
■common  symptom,  and  is  expressive  of  the  general  nervous 
irritability  of  the  patient.  Fatigue  symptoms  affecting  smell 
and  taste  are  also  usually  present,  but  are  usually  less  pro- 
nounced ;  however,  some  neurasthenics  complain  excessively  of 
various  odors,  or  of  the  taste  of  various  articles  of  food. 

Motor  Symptoms.  The  primary  motor  symptom  is,  again, 
ready  exhaustion.  There  is,  however,  no  local  weakness,  and 
nothing  resembling  paralysis.  Tremor  is  often  present,  and  is 
a  fine  intention  tremor.  There  may  also  be  noted  at  times 
slight  muscular  twitchings,  in  small  muscular  bundles  here  and 
there ;  for  instance,  in  a  few  fibers  of  the  frontalis  of  one  side, 
or  in  one  or  both  orbiculares  palpebrarum ;  or  in  other  facial 
muscles. 

The  tendon  reactions  are  usually  slightly  exaggerated, 
though  they  may  be  normal.  Now  and  then  the  response  may 
even  be  diminished.  Ankle  clonus  has  been  noted,  but  it  is, 
as  a  rule,  faint  and  rapidly  disappearing.  A  Babinski  sign  is 
never  present. 


NEURASTHENIA.  581 

Psychic  Symptoms.  The  most  striking  psychic  symptom  is 
a  diminished  power  for  continued  mental  effort.  Brain-work 
sooner  or  later  brings  on  symptoms  of  exhaustion,  and  the 
patient  finds  it  increasingly  difficult  to  concentrate  his  atten- 
tion. This  symptom  may  greatly  alarm  the  patient,  giving 
him  the  idea  that  he  is  about  to  lose  his  mind.  The  patient 
is  likewise  unable  to  think  readily.  There  is  a  lack  of  spon- 
taneity of  thought.  This  the  patient  himself  realizes,  for  he 
declares  repeatedly,  "I  cannot  think."  Further,  the  tired  man 
has  not  the  same  will-power  or  aggressiveness;  he  soon  begins 
to  hesitate,  often  to  be  uncertain,  and  to  lack  decision.  Again, 
there  is  a  markedly  increased  irritability.  That  the  tired  man 
is  usually  a  cross  man  is  a  familiar  fact.  This  irritability  is 
expressive  of  a  diminished  self-control,  a  diminished  inhibition. 
Finally,  the  patient  who  is  chronically  tired  is  also  afraid; 
weakness  and  fear  go  hand-in-hand.  He  may  suffer  from  sud- 
den attacks  of  fear.  These  attacks  are  spontaneous,  apparently 
causeless  in  origin,  and  generalized  in  character.  They  may 
be  accompanied  by  pallor  of  the  face  and  palpitation  of  the 
heart,  just  as  is  normal  fear.  At  times  the  physical  signs  are 
very  pronounced ;  thus  there  may  be  sudden  weakness,  pallor, 
coldness  of  the  surface,  excessive  tachycardia,  and  even  re- 
laxation of  the  sphincters.  Such  attacks  may  be  mistaken 
for  hysteria,  but  they  bear  no  resemblance  to  the  latter  affec- 
tion. 

Attacks  of  fear  occurring  in  a  patient  previously  neuro- 
pathic may  give  rise  to  special  forms  of  fear,  such  as  the  fear 
of  being  alone  (monophobia),  or  the  fear  of  crowds  (anthro- 
pophobia)  ;  or  they  may  give  rise  to  various  obsessions  and 
morbid  anxieties.  The  states  resulting  have  been  described 
under  the  head  of  neurasthenic  or  neurasthenic-neuropathic 
insanities,  while  Janet  has  devised  for  them  the  convenient 
term,  psychasthenia. 

In  addition  to  the  other  psychic  phenomena,  the  patient 
frequently  suffers  from  insomnia.  Some  neurasthenics  cannot 
sleep  for  a  long  time  after  retiring;  others  fall  asleep  readily 
and  promptly,  but  awaken  at  intervals  through  the  night. 
Quite  commonly  the  patient  falls  asleep  from  exhaustion 
toward  morning,  but  this  sleep  is  unrefreshing;,  and  on  awak- 
ening the  patient  feels  tired  and  depressed.     Quite  commonly, 


582  DISEASES    OF   THE    NERVOUS    SYSTEM. 

too,  the  disturbed  sleep  of  neurasthenia  is  accompanied  by 
repeated  micturition. 

Somatic  Symptoms.  The  somatic  symptoms,  like  all  of  the 
symptoms  of  neurasthenia,  are  those  of  ready  exhaustion. 
Thus,  the  gastro-intestinal  symptoms  are  those  due  to  atony 
and  deficient  innervation  of  the  stomach  and  intestines.  Di- 
gestion is  delayed  and  enfeebled,  and  constipation  is  the  rule. 
The  circulatory  S3^mptoms  consist  in  a  lessening  of  the  force 
and  modifications  of  the  rhythm  of  the  heart's  action,  of  the 
character  and  frequency  of  the  pulse,  and  of  changes  in  the 
vasomotor  tone.  Palpitation  of  the  heart  is  a  common  symp- 
tom ;  at  times  it  is  associated  with  the  digestive  disturbances, 
at  others,  with  attacks  of  fear.  Coldness,  dampness,  and  livid- 
ity  of  the  hands  and  feet  are  also  common  symptoms. 

Disturbances  of.  the  secretions  are  also  present,  likewise 
dependent  upon  deficient  innervation.  Thus,  the  skin  is  quite 
commonly  moist,  especially  of  the  hands  and  feet,  which  may 
be  cold  and  clammy.  At  times,  again,  the  patient  sweats  ex- 
cessively upon  relatively  slight  exertion.  At  other  times  the 
skin  is  unusually  dry.  The  urine,  too,  may  reveal  changes,  such 
as  an  increase  or  a  decrease  in  volume.  Changes  are  also  noted 
in  the  character  both  of  the  sweat  and  of  the  urine,  but  these 
are  secondary,  and  cannot  detain  us. 

The  sexual  phenomena  of  neurasthenia  are,  again,  those  of 
weakness  and  irritability.  Diminished  desire  and  power,  pre- 
mature ejaculation,  diminution  of  the  sensations  normally 
present,  are  among  the  common  symptoms  complained  of.  In 
addition,  others  may  be  noted,  dependent  upon  the  sex  and 
the  habits  of  the  patient;  for  instance,  in  young  unmarried 
men,  excessive  frequency  of  seminal  emissions,  and  in  young 
women  the  occurrence  of  the  orgasm  spontaneously  during 
sleep. 

TREATMENT. 

The  treatment  of  neurasthenia  resolves  itself  into  three 
factors :  the  application  of  rest,  the  administration  of  food,  and 
the  elimination  of  waste  substances.  The  last  indication  is 
met  by  attention  to  the  action  of  the  skin,  kidneys  and  bowels. 
The  methods  used  will  necessarily  have  to  be  adapted  to  each 


NEURASTHENIA.  583 

patient  individually.  If  the  exhaustion  is  tlfe  result  of  over- 
work or  overstrain  of  the  nervous  system,  this  must,  of  course, 
be  corrected,  and  excesses  of  all  kinds  must  be  guarded  against. 
These  measures  of  themselves  afford  in  many  instances  de- 
cided relief.  However,  in  the  majority  of  cases^  the  institution 
of  rest  as  a  therapeutic  measure  is  imperative.  Rest  has  a 
very  wide  application,  and  may  vary  very  greatly  in  degree. 

Partial  Rest  Methods.  If  the  neurasthenia  is  not  too  severe, 
or  if  the  patient  finds  himself  in  such  circumstances,  financial 
or  otherwise,  that  he  cannot  take  a  complete  rest,  we  must  use 
so-called  partial  rest  treatment.  As  a  matter  of  fact,  we  are 
forced  to  adopt  this  method  in  a  very  large  number  of  cases. 

The  patient  should  be  instructed  to  diminish  his  work  as 
much  as  possible,  at  least  so  much  as  is  unphysiological,  and 
at  the  same  time  increase  his  hours  of  rest  to  the  fullest  extent 
possible.  He  should  retire  not  later  than  9  o'clock,  and  rest 
in  bed  as  many  hours  as  his  work  will  permit,  e.g.,  he  should, 
if  possible,  spend  ten  hours  in  bed.  After  his  midday  meal 
he  should  lie  down  again  for  one  or  two  hours.  Both  morning 
and  afternoon,  however,  he  should,  if  possible,  exercise  gently 
in  the  open  air,  but  never  to  the  point  of  fatigue. 

Along  with  attention  to  the,  hours  of  rest  we  should  take 
up  the  question  of  diet.  The  food  should  be  such  as  will  be 
easily  digested,  and  in  as  large  amounts  as  possible.  Milk 
especially  should  be  added  to  the  diet.  Many  neurasthenics 
claim  they  cannot  digest  milk,  and  in  these  cases  the  patients 
should  begin  by  taking  very  small  amounts  after  meals,  be- 
tween meals,  and  at  bedtime.  Taken  in  this  manner  the  quan- 
tity can  be  gradually  increased  until  the  patient  is  taking  six 
full  glasses  of  milk  daily  in  addition  to  his  other  food.  Red 
meats  are  stimulating,  but,  as  a  rule,  do  not  agree  with  neuras- 
thenics. The  excessive  use  of  starches  and  sweets  is  likewise 
to  be  avoided.  The  white  meats,  fish,  chicken,  oysters  and 
eggs  should  be  taken  freely,  as  also  the  succulent  vegetables. 
Spinach,  lettuce,  celery,  ripe  and  stewed  fruits  are  valuable. 
Whole  cereals,  as  wheat  or  oatmeal,  and  bran-breads  are  also 
indicated.  In  other  words,  a  liberal  mixed  diet,  with  the  addi- 
tion of  milk  and  eggs,  is  the  best  for  a  neurasthenic.  All 
stimulants,  alcohol,  tea,  coffee  and  tobacco,  are  contraindi- 
cated.    Under  certain  conditions,  it  may  be  necessary  to  allow 


584  DISEASES    OF   THE    NERVOUS    SYSTEM. 

a  cup  of  coffee  'or  tea  in  the  morning,  but  usually  a  cup  of 
cocoa  or  hot  milk  will  be  found  to  be  equally  acceptable  to 
the  patient. 

Many  of  the  vague  aches  and  pains  which  attack  the 
neurasthenic  are  doubtless  due  to  faulty  elimination  and  the 
retention  of  waste  substances.  In  order  to  increase  the 
elimination  of  these  materials,  we  should  increase  the  amount 
of  liquids  the  patient  consumes.  Most  neurasthenic  patients 
drink  too  little  water,  and  it  is  well  to  order  a  fixed  and  rather 
large  amount  to  be  taken  at  regular  intervals  between  meals. 
It  may  be  added,  in  this  connection,  that  milk  is  not  only  one 
of  the  most  useful  foods  for  these  patients,  but  being  a  liquid 
food  it  is  also  a  valuable  aid  in  elimination. 

The  skin  should  be  stimulated  by  bathing;  a  brief  immer- 
sion bath,  a  shower  or  a  sponge  bath,  followed  by  a  gentle 
rubbing,  will  answer  the  purpose.  A  warm  bath  in  the  even- 
ing, just  before  retiring,  is  both  relaxing  and  restful  to  the 
patient,  and  is  often  helpful  in  relieving  the  insomnia  from 
which  so  many  patients  suffer.  Because  of  the  general  weak- 
ness and  inability  to  react  to  cold  plunge  baths,  they  are  not 
indicated  in  neurasthenia.  However,  cold  sponge  baths  may 
be  used  in  the  mornings  just  after  rising.  The  application  of 
the  cool  sponge  and  rub-down  stimulates  the  patient  at  the 
time  his  energy  is  at  its  lowest  ebb.  Elaborate  apparatus  is 
not  necessary  to  apply  hydrotherapeutics  in  these  cases. 

Massage  may  be  employed,  and  in  a  measure  takes  the 
place  of  exercise.  It  is  likewise  a  valuable  aid  in  combating 
insomnia,  and,  of  course  for  this  purpose  it  is  given  just 
before  the  patient  retires  at  night. 

Electricity  sometimes  proves  to  be  of  benefit  in  some  cases. 
Quite  commonly  it  acts  merely  by  suggestion,  but  occasion- 
ally it  appears  to  have  a  distinctly  stimulating  effect.  Static 
electricity  is  the  form  most  commonly  employed. 

Full  Rest  Methods.  The  neurasthenia  may  be  so  pro- 
nounced that  it  becomes  necessary,  if  at  all  feasible,  to  put 
the  patient  to  bed  upon  absolute  rest.  To  obtain  good  results 
close  attention  must  be  paid  to  the  details  of  the  treatment. 
The  rest  must  be  as  complete  as  possible,  and  the  treatment 
is  of  course  best  carried  out  away  from  home,  under  absolute 
isolation.      The   patient   is    to    lie    quietly   in   bed,    sitting   up 


NEURASTHENIA.  585 

merely  to  take  food,  and  leaving  the  bed  only  to  empty  the 
bowels  or  bladder.  A  number  of  weeks  of  such  rest  is  usually 
sufficient  for  ordinary  cases,  but  at  times  a  much  longer  period 
is  required.  When  the  exhaustion  is  profound,  the  patient 
must  be  fed  by  the  nurse,  and  should  even  be  turned  in  bed  in 
the  endeavor  to  save  the  patient  all  exertion.  ]\Iental  excite- 
ment must  be  avoided,  and  relatives  and  friends  should  not  be 
permitted  to  visit  the  patient.  Further,  all  correspondence 
should  be  eliminated.  In  other  words,  complete  isolation  of 
the  patient,  with  only  the  physician  and  nurse  in  attendance,  is 
desirable.  Necessarily  this  rule  must  be  modified  at  times, 
according  to  the  case.  However,  most  patients  make  better 
progress  when  the  isolation  is  maintained. 

In  employing  full  rest  methods,  massage  is  indispensable. 
In  the  beginning  the  massage  should  be  used  gently,  and  for  a 
short  time  only.  Severe  and  deep  massage  may  increase  the 
fatigue.  Gradually,  as  the  patient  improves,  the  massage  may 
be  increased  to  one  hour  in  duration.  Passive  exercise  also 
proves  very  helpful. 

Electricity  is  not  as  valuable  as  massage.  It  is  useful  to 
stimulate  the  muscles,  and  is  indicated  toward  the  end  of  the 
rest  period,  that  is,  preparatory  to  getting  the  patient  out  of 
bed.  The  slowly  interrupted  faradic  current  is  the  one  usually 
indicated.  The  current  should  be  so  applied  as  to  evoke  in 
the  various  muscle  groups  a  certain  number  of  contractions. 
This  treatment  should  not  continue  over  twenty  to  forty 
minutes. 

The  diet  in  neurasthenia  has  already  been  outlined  under 
partial  rest  methods.  It  is  wise  to  begin  with  a  moderate 
amount  of  food.  At  times  it  may  be  best  to  begin  with  milk 
alone,  4  to  6  ounces  (120  to  180  mils)  at  meal-times,  between 
meals,  and  just  before  the  hour  for  sleep.  In  most  patients, 
however,  some  solid  food  can  be  given  in  the  beginning  of 
the  treatment. 

White  meats  should  be  preferred.  Vegetables  such  as 
spinach,  lettuce,  celery,  squash  and  later  peas  and  string  beans 
may  be  added  until  a  full  diet  is  reached.  Potatoes  should  not 
be  given  for  some  time,  and  then  not  in  large  quantities. 
Wheat  bread  also  should  only  be  permitted  in  limited  amount. 
The  neurasthenic  needs  a  mixed  diet,  one  that  will  supply  all 


586  DISEASES    OF   THE    NERVOUS    SYSTEM. 

that  the  tissues  require,  but  the  full  diet  must  be  approached 
gradually. 

The  milk  should  be  slowly  increased  in  quantity,  until  the 
patient  takes  from  8  to  12  ounces  (240  to  360  mils)  six  times 
daily.  Often  the  patient  objects  to  milk,  either  because  he 
dislikes  it,  or  because  of  inability  to  digest  it.  In  such  cases 
the  milk  may  be  modified  in  various  ways.  A  little  salt 
added  to  the  milk  will  in  some  instances  be  helpful;  in  others 
the  addition  of  some  alkaline  waters,  such  as  Vichy,  ApoUi- 
naris  or  plain  soda-water.  Further,  the  milk  may  be  pre- 
digested,  or  some  digestive  powder  added  to  the  milk  just 
before  it  is  taken.  Buttermilk  is  valuable,  especially  when 
the  patient  sufifers  from  constipation.  Whey  also  may  be 
used,  though  its  nourishing  qualities  are  of  course  greatly 
inferior  to  that  of  milk.  Kuymiss,  i.e.,  imitation  kumyss,  is 
of  much  more  value  than  whey,  and  is  frequently  well  di- 
gested when  milk,  even  modified,  fails.  At  times  it  becomes 
necessary  to  discontinue  milk  altogether,  and  then  egg-feed- 
ing may  be  resorted  to.  Eggs  are  best  given  raw.  The  egg 
is  broken  into  a  glass,  leaving  the  yolk  whole.  The  patient 
can  soon  learn  to  swallow  it  with  a  single  effort.  If  neces- 
sary, a  pinch  of  salt  or  a  few  drops  of  lemon  juice  will  render 
the  egg  more  palatable.  The  patient  should  begin  with  1  egg 
between  meals,  this  being  gradually  increased  so  that  the 
patient  after  a  time  takes  6  or  more  eggs  daily. 

The  neurasthenic,  at  rest  in  bed,  can  digest  and  assimilate 
large  amounts  of  food.  Great  care  must  be  given  to  the 
digestive  tract ;  especially  must  constipation  be  guarded 
against.  The  skin  also  should  be  kept  active  by  sponge  bath- 
ing, and  massage  should  be  given  thoroughly.  As  a  rule,  a 
rapid  increase  of  weight  is  noted  under  these  circumstances. 

The  patient  should  have  a  special  nurse^  who  devotes  all 
of  her  time  to  the  patient.  In  the  case  of  male  patients,  it  is 
of  course  necessary  that  the  nurse  should  be  of  the  same  sex. 
The  nurse  should  sleep  in  the  same  room,  or  one  adjoining 
that  of  the  patient.  The  patient  should  be  prepared  for  a 
period  of  absolute  quiet  between  the  hours  of  two  and  four  in 
the  afternoon ;  many  patients  learn  to  sleep  during  this  time. 
It  will  be  found  most  convenient  also  to  have  the  nurse  take 
her  hours  off  for  recreation  and  change  at  this  time.     It  is 


NEURASTHENIA.  587 

needless  to  add  that  the  nurse  must  have  both  patience  and 
tact,  and  must  in  her  conversation  direct  the  patient's  thoughts 
aw^ay  from  her  ills  and  into  pleasant  and  healthful  channels. 
It  is  best  also  that  the  nurse  herself  should  give  the  massage. 
A  strange  masseuse  coming  in  for  this  purpose  often  disturbs 
the  patient,  and  in  this  way  may  retard  her  progress. 

If  the  details  of  the  treatment  are  properly  carried  out,  the 
patient  will  gradually  improve.  There  is  a  decided  gain  in 
weight,  the  circulation  improves,  the  extremities  cease  to  be 
cold,  the  muscles  become  firm,  and  the  color  of  the  skin  grad- 
ually assumes  the  appearance  of  health ;  the  nervousness  and 
restlessness  begin  to  disappear,  and  little  by  little  the  patient 
feels  at  ease,  comfortable  and  relaxed.  Sooner  or  later,  how- 
ever, if  the  treatment  is  successful,  some  return  of  spon- 
taneity is  observed.  The  patient  becomes  more  active  men- 
tally, and  the  inclination  to  exert  himself  becomes  manifest. 
As  soon  as  the  maximum  amount  of  improvement  has  been 
reached,  as  is  indicated  by  a  cessation  in  the  increase  of  weight, 
and  by  a  rather  pronounced  desire  on  the  part  of  the  patient 
for  activity,  we  should  begin  getting  the  patient  out  of  bed. 
This  period  is  not  reached  before  six,  eight,  ten  or  twelve  weeks 
have  passed.  The  patient  should  at  first  sit  up  for  from  five  to 
ten  minutes  once  or  twice  daily.  Very  gradually  this  time 
should  be  increased  until  five  to  six  hours  out  of  the  twenty- 
four  are  spent  out  of  bed.  Light  passive  exercise,  Swedish 
movements  with  resistance,  and,  later,  calisthenics,  should  be 
instituted. 

Walking  in  the  open  air  or  an  occasional  drive  should  at 
this  time  be  permitted!  The  time  out  of  bed  being  steadily 
increased,  the  patient  is  out  of  bed  the  greater  part  of  the  day ; 
rising  at  10.30  in  the  morning,  lying-  down  between  two  and 
four,  and  going  to  bed  soon  after  the  evening  meal.  A  little 
later  the  time  is  still  further  increased,  but  the  patient  is 
instructed  to  still  take  his  breakfast  in  bed,  and  to  lie  down 
between  two  and  four.  Finally  it  becomes  necessary  to  send 
the  patient  away.  Preferably  he  should  not  go  directly  to  his 
home,  iDUt  should  go  for  a  period  of  about  two  weeks  to  the 
seashore,  country,  or  mountains.  During  this  period  the 
patient  may  gradually  resume  an  ordinary,  every-day  plan  of 
living,  and  begin  resuming  communication  with  friends.     It  i§ 


588  DISEASES    OF   THE   NERVOUS    SYSTEM. 

important  to  emphasize  the  fact  that  after  a  course  of  rest 
treatment  it  is  very  important  that  the  patient  should  adopt 
some  regular  form  of  exercise,  especially  out  of  doors.  One 
important  point,  however,  must  be  borne  in  mind,  and  that  is, 
that  the  exercise  should  always  stop  short  of  fatigue.  Such 
a  course  leads  to  permanent  and  durable  results.  A  strictly 
physiologic  mode  of  life  should,  of  course,  be  insisted  upon. 
If  possible,  the  patient  should  be  induced  to  take  up  some 
agreeable  and  useful  occupation.  Work  within  physiological 
limits  is  beneficial  to  both  the  mental  and  physical  condition 
of  a  patient.  Indeed  it  may  be  questioned  whether  a  high  level 
of  health  can  be  maintained  without  it. 

The  reader  will  observe  that  thus  far  nothing  has  been 
said  of  medication,  and  indeed  in  many  cases  no  medication 
will  be  required.  At  times  the  insomnia  may  be  so  severe  as 
not  to  yield  to  massage  or  hydrotherapy,  e.g.,  the  warm  bath 
or  drip-sheet.  In  such  instances  it  may  be  necessary  to  use 
medicines,  such  as  the  bromids,  luminal,  medinal,  trional^  sul- 
phonal  or  veronal.  These  remedies  should  not,  however,  be 
continued  long,  nor  should  they  be  given  in  large  doses.  The 
best  results  are  often  obtained  by  not  giving  the  same  drug 
continuously,  but  by  changing  from  one  to  another.  Morphin 
is  rarely,  if  ever,  necessary  and  chloral  also  is  rarely  indicated. 
The  milder  remedies  above  enumerated  as  a  rule  answer  every 
purpose. 

Little  also  has  been  said  of  psychotherapy,  and  it  may  be 
here  remarked  that  only  such  psychotherapy  as  is  contained  in 
the  suggestion  that  the  patient  is  getting  well  is  of  value. 
Neurasthenia  has  as  its  basis  an  underlying  physical  condition, 
and,  until  this  is  corrected,  suggestion  is  of  but  little  avail.  To 
be  sure,  cheerful  and  bright  surroundings  are  of  value  here  as 
in  other  alfections,  but  no  reason  exists  for  the  employment  of 
hypnosis,  psychanalysis,  or  other  special  psychotherapeutic 
procedure. 

At  times  it  may  be  necessary  to  prescribe  tonics,  such  as 
arsenic,  or  iron,  especially  if  surface  pallor  be  marked,  or  at 
times  strychnia  may  be  indicated. 


HYSTERIA.  589 

HYSTERIA. 

Hysteria  may  be  defined  as  an  innate  neuropathy,  the 
various  symptoms  of  which  present  the  intrinsic  evidence  of  a 
mental  origin,  and  which  is  characterized  by  a  pathological 
susceptibility  to  suggestion,  and  by  an  emotional  instability. 

Heredity  is  a  strongly  predisposing  factor.  In  many  cases 
there  is  a  family  history  of  hysteria;  sometimes  of  other 
nervous  afifections.  Charcot  maintained  that  hysteria  was 
always  hereditary.  It  may  occur  in  either  sex  and  at  almost 
any  age.  Persons  of  an  emotional,  impassionable  and  non- 
resisting  make-up  more  frequently  manifest  its  symptoms  than 
others.  That  the  patient  is  innately  neuropathic  is  revealed  by 
a  brief  study  cf  the  symptoms. 

In  early  times  the  symptoms  of  hysteria  were  ascribed  to 
disorders  of  the  womb.  The  name  of  the  affection  is  indeed 
derived  from  ia-repa  (hystera),  the  Greek  word  for  womb.  The 
Greeks  believed  that  in  an  hysterical  attack  the  womb  becomes 
detached  from  its  moorings  and  goes  wandering  about  the 
body  seeking  sexual  satisfaction.  It  was  not  until  the 
seventeenth  century  that  it  was  described  by  a  French 
physician  (Charles  Lepois)  as  a  nervous  affection,  and  it  was 
not  until  the  latter  part  of  the  nineteenth  century  that  its 
symptoms  were  carefully  studied  by  Charcot,  Paul  Richer,  and 
Gilles  de  la  Tourette.  It  was  Babinski,  however,  who  estab- 
lished the  true  nature  of  hysteria.  Babinski  failed  in  one 
hundred  consecutive  cases  of  hysteria,  not  previously  examined 
by  physicians,  and  in  which  he  carefully  avoided  suggestion,  to 
note  in  a  single  instance  the  presence  of  hemianesthesia.  Evi- 
dently this  symptom,  which  up  to  his  day  had  been  one  of 
those  most  frequently  observed  in  the  clinics,  was  produced 
in  the  patient  by  the  suggestion  of  the  physician's  examination ; 
that  is,  it  was  an  artefact.  This  proved  to  be  true  of  all  the 
other  symptoms  of  hysteria.  In  other  words,  in  hysteria  the 
various  symptoms  observed  are  the  result — of  course,  inad- 
vertent— of  the  suggestions  presented  by  the  medical  examina- 
tion, or  they  are  the  result  of  suggestion  derived  from  other 
sources. 

Again,  it  is  found  to  be  impossible  to  elicit  a  given  symp- 
tom such  as  anesthesia  in  a  normal  individual,  even  when 


590  DISEASES    OF   THE    NERVOUS    SYSTEM. 

direct  suggestion  is  employed.  Evidently  the  hysterical 
individual  is  pathologically  vulnerable  to  suggestion,  i.e.,  he  is 
the  sufferer  from  a  pre-existing  and  innate  neuropathy. 

In  Charcot's  time  the  symptoms  of  hysteria  were  elab- 
orately classified  and  charted,  but  since  the  introduction  of 
Babinski's  method — that  is,  of  examinations  without  sugges- 
tion— these  symptoms  have  to  a  large  extent  disappeared  from 
our  clinics.  Such  symptoms  as  are  still  met  with  have  their 
origin  in  other  sources  of  suggestion  than  medical  examina- 
tions, or  in  medical  examinations  that  have  been  improperly  or 
unskilfully  made. 

Bearing  in  mind  the  purely  mental  character  of  the  symp- 
toms and  their  origin  in  suggestion,  it  is  easy  to  understand 
that  the  symptoms  elicited  bear  no  relation  to  the  facts  of 
anatomy ;  the  symptom  of  anesthesia  in  a  given  case,  for 
instance,  presents  no  relation  to  the  facts  of  nerve  supply  and 
distribution.  Equally  the  phenomena  met  with  frequently 
stand  in  crass  contradiction  to  the  well-known  and  established 
facts  of  physiology. 

It  has  been  the  custom,  especially  in  past  years,  to  divide 
the  symptoms  into  sensory,  motor,  psychic  and  visceral  phe- 
nomena. These  we  will  briefly  enumerate,  bearing  in  mind, 
however,  that  they  are  observed,  if  at  all,  typically  in  much- 
studied  and  long-standing  cases. 

Sensory  Symptoms. — Anesthesia,  hypesthesia,  paresthesia, 
or  hyperesthesia  may  variously  be  noted.  The  areas  involved 
present  no  relation  to  nerve  distribution  or  to  spinal  segmenta- 
tion. The  anesthesia  may  involve  a  hand,  like  a  glove,  and  in 
such  instance  is  spoken  of  as  a  glove-like  anesthesia ;  or  a  foot 
and  leg,  like  a  stocking,  i.e.,  a  stocking-like  anesthesia.  Some- 
times a  mere  segment  of  a  limb  is  anesthetic,  or  isolated 
patches  may  be  distributed  over  various  parts  of  the  body,  e.g., 
the  face,  trunk,  as  well  as  the  limbs;  or  the  anesthesia  may 
afifect  one-half  of  the  body,  being  sharply  limited  by  the  middle 
line.  Usually  all  forms  of  sensation  are  involved,  but  in  some 
cases  a  dissociated  loss  of  sensation  is  present,  i.e.,  a  loss  of  the 
pain  sense  or  the  temperature  sense  without  loss  of  the  tactile 
sense.  There  may  be  isolated  patches  of  hyperesthesia  or 
hyperalgesia,  located  over  the  spine,  beneath  the  breasts,  such 
as    areas    of   inframammary    tenderness,    or   over   the   groins, 


HYSTERIA.  591 

namely,  areas  of  inguinal  tenderness ;  or  it  may  be  over  any 
other  part  of  the  body,  head  or  limbs.  The  tenderness  is  not 
genuine,  is  always  superficial,  and  disappears  upon  deep  pres- 
sure. The  areas  are  found  more  frequently  on  the  left  side  of 
the  body.  At  times  they  are  found  on  the  mucous  membranes, 
even  in  the  vagina  and  rectum. 

As  regards  the  special  senses,  e.g.,  the  eye,  contraction  of 
the  visual  field  may  be  elicited.  In  keeping  with  suggestion, 
contraction  of  the  field  is  developed  on  the  same  side  of  the 
body  in  which  there  is  also  a  hemianesthesia.  In  former  years 
elaborate  studies  were  made  of  "contracture  of  the  color  fields," 
but  these,  like  contracture  of  the  visual  fields  in  general,  are 
now  known  to  be  artefacts. 

Similarly  hysteric  deafness  may  be  elicited.  This  is 
usually  incomplete,  the  hearing  being  merely  impaired.  Bone 
conduction  is  well  preserved.  There  is  generally  associated 
anesthesia  of  the  external  auditory  meatus,  often  of  the  drum, 
and  at  times  of  the  auricle.  Loss  of  smell  and  taste  may  like- 
wise be  elicited  in  hysteria. 

Motor  Symptoms.  The  motor  phenomena  of  hysteria 
express  themselves  as  palsies,  contractures,  tremors  and  inco- 
ordination. 

The  palsy  may  take  any  form,  hemiplegia,  paraplegia,  or 
monoplegia.  With  the  palsy  there  is  frequently  associated 
anesthesia  of  the  paralyzed  part.  Contractures  in  hysteria 
rarely  simulate  the  contractures  seen  in  organic  disease,  though 
at  times  the  palsy  may  simulate  a  paraplegia  or  hemiplegia. 
The  tremor  usually  consists  of  to-and-fro  oscillations  varying 
from  four  to  twelve  per  second ;  however^  more  frequently  the 
rate  is  from  seven  to  nine  in  a  second.  The  tremor  does  not 
resemble  either  that  of  paralysis  agitans  or  of  multiple 
sclerosis. 

Incoordination  may  express  itself  as  astasia  abasia ;  i.e.,  the 
movements  of  the  patient  will  betray  no  ataxia  when  lying  in 
bed  or  while  sitting,  but  when  the  patient  attempts  to  stand  or 
to  walk  incoordination  makes  its  appearance,  and  usuall}' 
becomes  very  marked.  The  gait  does  not  resemble  either  that 
of  tabes  or  of  cerebellar  disease.  It  is  extremely  irregular ; 
wide,  oscillatory,  coarse  or  grossly  bizarre  movements  of  the 
legs,  arms  and  trunk  are   commonly   observed.     The   tendon 


592  DISEASES    OF   THE    NERVOUS    SYSTEM. 

reflexes  in  hysteria  do  not  present  constant  phenomena.  They 
may  be  somewhat  exaggerated,  though  never,  unless  the 
patient  has  been  trained  by  suggestion,  to  the  degree  seen  in 
organic  disease.  They  are  seldom  diminished,  and  never  really 
lost,  though  here  a  caution  is  necessary,  as  some  persons  in 
apparent  health  never  have  a  knee-jerk.  The  latter  is  also  nor- 
mally absent  in  many  children.  Similar  remarks  apply  to  the 
Achilles-jerk  and  to  the  ankle  clonus;  a  persistent  ankle  clonus 
may,  however,  though  rarely,  be  noted.  The  skin  reflexes  may 
not  be  at  all  modified,  though  they  may  be  diminished.  They 
may  even  be  lost  in  an  anesthetic  limb.  A  Babinski  sign  is 
never  present. 

Somatic  Symptoms.  Among  the  visceral  manifestations  of 
hysteria  we  note  vomiting,  rapid  pulse,  vasomotor  disturb- 
ances, rapid  breathing,  cough,  yawning,  retention  of  urine, 
anuria,  phantom  tumor,  aphonia,  spurious  aphasia,  and  other 
bizarre  phenomena. 

Hysteric  vomiting  is  often  associated  with  anorexia  ner- 
vosa, i.e.,  with  nervous  loss  of  appetite.  Pain  may  be  com- 
plained of,  and  may  lead  to  the  erroneous  diagnosis  of  organic 
disease.  When  circulatory  disturbances  are  present,  such  as 
tachycardia,  flushings,  pallor,  coldness,  lividity  or  dermato- 
graphia,  their  functional  nature  is  at  once  apparent.  Occa- 
sionally hysteric  rapid  breathing  may  be  present.  Frequently 
this  symptom  is  unassociated  with  any  change  in  the  pulse 
rate ;  there  is  no  cyanosis,  dyspnea,  or  cardiac  distress. 
Hysteric  cough  is  accompanied  by  no  physical  signs;  the 
cough  may  assume  a  bizarre  form,  and  may  suggest  the  crow- 
ing of  a  cock  or  the  yelping  of  a  dog.  Hysteric  yawning  is 
usually  frequently  repeated,  exaggerated  and  prolonged. 

The  sphincters  are  not  involved  in  hysteria.  The  patient 
may  claim,  among  other  things,  that  she  has  anuria,  but  the 
grave  symptoms  of  suppression  of  urine  are  never  present. 
Polyuria  is  frequent ;  in  such  case  the  patient  passes  large 
quantities  of  pale  urine  of  a  low  specific  gravity. 

The  abdomen  may  at  times  be  greatly  distended,  or  the 
appearance  of  pregnancy  simulated.  The  distention  may  be 
irregular  or  limited  in  outline,  and  give  rise  to  a  so-called 
"phantom  tumor."  Needless  to  say,  examination  soon  reveals 
the  nature  of  the  symptom ;  the  ballooning  proves  to  be  due  to 


•     HYSTERIA.  593 

gas-distention  and  the  tumors  to  localized  spasms  of  the 
abdominal  muscles. 

Psychic  Symptoms.  The  psychic  state  in  hysteria  has 
already  been  sufficiently  indicated;  suffice  it  to  repeat  that, 
owing  to  his  innate  neuropathy,  the  patient  reacts  abnormally, 
and  at  the  same  time  suffers  from  a  marked  emotional  instabil- 
ity. Paralysis,  convulsions,  nausea,  vomiting,  blindness,  all 
have  their  origin  in  suggestion.  Hysteria,  too,  may  be  con- 
tagious ;  symptoms  may  be  communicated  from  one  hysterical 
patient  to  another.  The  mental  attitude  is  always  introspec- 
tive, and  the  patient  manifests  an  inordinate  craving  for 
sympathy. 

Sometimes  hysterical  crises  supervene.  These  present 
symptoms  which  vary  greatly.  The  latter  may  consist  of  light 
emotional  storms  attended  by  laug-hing  and  crying,  or  by 
transient  alterations  of  conduct,  the  emotional  character  of 
which  is  apparent.  On  the  other  hand,  the  attack  may  be  more 
pronounced.  In  such  case,  it  is  usually  preceded  by  a  period 
of  depression  and  irritability,  during  which  the  patient  for 
slight  causes  weeps  or  laughs.  This  stage  may  last  for  several 
days,  and  hysterical  symptoms,  already  present,  become  more 
marked,  or  new  ones  make  their  appearance.  Sooner  or  later 
a  convulsion  ensues.  There  is  first  a  tonic  spasm,  including 
the  muscles  of  the  trunk  and  extremities.  Unlike  epilepsy,  this 
tonic  spasm  may  be  quite  prolonged.  Sooner  or  later,  how- 
ever, it  is  followed  by  a  clonic  spasm,  which  after  a  time  sub- 
sides. The  patient  is  never  unconscious.  At  times  the  patient 
passes  through  a  series  of  bizarre  motions,  contorting  the  body 
into  various  positions,  suggestive  of  volition  or  purpose,  or  the 
patient  may  assume  dramatic  or  passionate  attitudes,  accom- 
panied by  cries  and  weeping.  Later  the  patient  becomes  quiet 
and  may  fall  asleep. 

At  times  the  rigidity  becomes  so  pronounced  as  to  consti- 
tute a  catalepsy.  At  others  the  patient  passes  into  a  condition 
of  ecstasy.  At  other  times  still  the  patient  may  pass  into  a 
condition  of  lethargy,  or  the  somnambulism,  or  the  sleep  of 
hypnosis  may  be  simulated. 


38 


594  DISEASES    OF   THE    NERVOUS    SYSTEM. 

TREATMENT. 

The  physician  in  his  examination  and  treatment  of  a  case 
of  hysteria  should  be  careful  that  by  sugg'estion  he  does  not 
induce  new  symptoms  or  make  worse  those  already  present. 
Elaborate  and  prolonged  examinations,  frequently  repeated, 
and  especially  if  made  by  different  physicians,  are  baneful  in 
their  effects.  A  careful  physical  examination  should  of  course 
be  made  of  every  medical  case,  but  care  should  be  taken  that 
no  inadvertent,  indirect  or  other  suggestion  be  conveyed  to  the 
patient  that  might  be  harmful  in  its  effects.  On  the  contrary, 
the  examination  should  be  conducted  in  such  a  way  as  to 
suggest  to  the  patient  that  there  is  nothing  very  serious  the 
matter.  On  the  other  hand,  the  physician  should  frankly 
admit  the  existence  of  the  symptoms  from  which  the  patient 
complains,  at  the  same  time  giving  the  patient  the  impression 
that  he  does  not  regard  the  symptoms  as  of  great  consequence. 
It  is  important  when  marked  stigmata,  such  as  anesthesia  or 
paralysis  are  present,  to  lay  as  little  stress  on  them  as  possible. 
The  patient  is  usually  encouraged  by  being  told  that  the  symp- 
toms are  not  dangerous,  and  that  she  will  make  a  good  recov- 
ery. However,  hysteric  patients  are  frequently  very  jealous  of 
their  symptoms,  dwell  upon  them  insistently,  and  are  anxious 
to  impress  the  physician  with  their  severity.  Needless  to  say, 
all  the  patient's  complaints  should  be  listened  to  patiently.  It 
is  only  in  this  way  that  confidence  is  established,  and  it  is  only 
by  establishing  confidence  that  the  physician  will  be  able  later 
to  influence  the  patient  by  suggestion.  Tact,  patience,  and  a 
judicious  sympathy  must  be  maintained  throughout.  Finally, 
the  examination  should  be  made  largely  from  the  standpoint  of 
internal  medicine.  The  patient  does  not  believe  herself  to  be 
hysterical,  and  to  tell  her  so  often  does  great  harm.  It  should 
never  be  forgotten  also  that  hysteria  is  now  and  then  present, 
when  there  is  also  actual  organic  disease ;  especially  may  we 
meet  with  this  complication  in  girls  and  young  women. 

If  in  a  given  case  the  hysteria  be  severe,  the  patient  should, 
if  possible,  be  put  to  bed,  and  a  course  of  radical  rest  treatment 
instituted.  This  will  give  the  physician  an  opportunity  to 
relieve  the  symptoms,  the  result  of  the  patient's  unphysiologic 
habits  of  living,  and  the  sense  of  comfort  and  well-being  that 


HYSTERIA.  595 

results  froni  a  properly  conducted  rest-cure  is  of  itself  a  power- 
ful suggestion  of  a  returning  health.  Isolation  is  here  of  the 
greatest  importance.  Otherwise,  the  comments  and  solicitous 
sympathy  of  well-meaning  but  mistaken  friends  and  relatives 
make  nugatory  the  best  efforts  of  the  physicians. 

It  is  of  course  very  important  that  the  nurse  should  be  in 
full  possession  of  the  details  and  nature  of  the  case,  that  she 
should  be  endlessly  tactful,  gentle  and  firm,  and  that  above  all 
she  should  at  all  times  keep  up  the  suggestion  that  the  patient 
will  get  well.  No  hard-and-fast  rules  can  be  given  to  govern 
the  conduct  of  the  nurse,  save  to  carefully  observe  the  instruc- 
tions of  the  physician  in  every  detail,  and  to  keep  him  informed 
as  to  the  changing  aspects  of  the  case. 

The  details  of  the  rest  treatment  have  been  fully  con- 
sidered in  the  treatment  of  neurasthenia,  to  which  section  the 
reader  is  referred.  However,  symptoms  at  times  arise  requir- 
ing special  attention,  and  often  necessitating  a  modification  of 
the  general  plan  of  treatment.  It  may  be  that  the  patient 
centers  her  thoughts  on  one  special  feature  of  her  case,  such 
as  a  painful  area,  a  palsy,  vomiting,  or  retention  of  urine.  Here 
success  often  depends  upon  the  resourcefulness  of  the  physi- 
cian and  the  conscientious  co-operation  of  the  nurse. 

Painful  sensory  areas  should  be  treated  by  massage,  or  by 
hot  and  cold  douching.  At  times,  various  forms  of  electricity 
are  helpful.  A  nurse  skilful  in  giving  massage  may  "rub  out" 
the  painful  area,  and,  occasionally,  a  placebo,  such  as  a  cap- 
sule containing  starchy  when  given  coupled  with  the  sugges- 
tion that  it  will  give  relief,  is  effectual.  Inguinal  tenderness 
may  be  very  persistent,  and  give  rise  to  the  belief  in  the  exist- 
ence of  some  ovarian  trouble  or  appendicitis.  However,  the 
measures  here  indicated,  if  persisted  in,  will  usually  prove  suc- 
cessful. 

In  the  case  of  a  palsy,  the  patient  should  be  encouraged  to 
make  the  effort  to  move  the  affected  part,  and  also  taught  to 
do  so.  Suggestion  proves  in  such  instances  very  serviceable  ; 
e.g.,  the  patient  is  told  she  is  succeeding,  and  that  the  muscles 
are  becoming  stronger  each  day.  In  such  cases,  too,  massage 
and  electricity  are  of  decided  benefit,  and  are  a  valuable  aid  to 
the  suggestion.  If  the  palsy  be  a  monoplegia,  it  is  well  to  have 
the  patient  make  some  desired  movement  with  the  unparalyzed 


596  DISEASES   OF  THE   NERVOUS    SYSTEM. 

member  first,  and  then  to  try  the  same  movements  with  both 
limbs.  Many  times  a  paralysis  rapidly  disappears  after  a  skil- 
fully made  sug-gestion. 

It  need  not  be  stated  that  the  chief  benefit  of  massage  and 
electricity  in  a  hysteric  palsy  is  due  to  the  suggestion.  The 
faradic  current  may  be  all  that  is  necessary.  However,  the 
static  spark  or  the  high  frequency  applied  by  means  of  a 
vacuum  electrode  are  doubly  suggestive,  as  their  application 
is  visible  and  impressive.  Palsies  as  well  as  contractures  are 
at  times  exceedingly  difficult  to  combat.  In  these  cases,  pas- 
sive movements,  in  addition  to  electricity  and  suggestion,  are 
also  of  benefit.  In  the  experience  of  the  writers,  contractures 
are  more  difficult  to  treat  than  palsies.  If  contractures  persist 
for  too  long  a  time,  a  certain  degree  of  actual  fixation  may  take 
place  in  the  joints  and  fibrous  tissues.  Under  such  circum- 
stances it  is  proper  to  overcome  the  condition  by  free  move- 
ments, and,  if  necessary,  giving  at  the  time  an  anesthetic.  Con- 
tractures, with  few  exceptions,  disappear  while  the  patient  is 
asleep,  or  while  he  is  under  the  influence  of  the  anesthetic. 
However,  at  times  actual  changes  have  taken  place  in  the 
joints  and  fibrous  tissues,  and  in  these  cases  the  contracture 
persists.  As  soon  as  the  condition  present  is  fully  ascertained, 
treatment  by  passive  motion  should  be  given  daily,  combined 
with  suggestion,  and  the  control  of  the  will  over  the  affected 
limb  should  be  stimulated  as  much  as  possible. 

Astasia  abasia,  or  hysterical  ataxia,  should  be  treated  by 
exercise  of  precision,  i.e.,  hy  efforts  at  retraining,  together  with 
the  judicious  use  of  suggestion. 

Vomiting,  nausea,  and  loss  of  appetite  are  difficult  symp- 
toms to  treat.  In  anorexia  nervosa  the  articles  of  food  which 
the  patient  objects  to  or  refuses  to  take  are  generally  those 
which  she  needs  the  most.  At  times  everything  is  objected  to, 
and  the  patient  takes  and  retains  only  very  small  quantities  of 
nourishment,  if  any.  Usually  she  declares  that  the  taking  of 
food  produces  nausea;  even  the  taking  of  liquids  may  be  fol- 
lowed by  eructations,  belching  of  large  amounts  of  gas,  and 
retching  and  marked  distention  of  the  abdomen.  At  times, 
indirect  suggestion  is  very  helpful.  Thus  the  milk  or  some 
other  article  of  food  may  be  emphatically  and  ostentatiously 
forbidden.      Again,    the    nurse    having    been    previously    in- 


HYSTERIA.  597 

structed,  may  mention  a  given  article,  and  in  reply  the  physi- 
cian should  treat  it  as  of  no  consequence.  In  such  case  the 
patient,  inasmuch  as  the  article  of  food  is  not  being  forced 
upon  her,  may  ask  the  physician  whether  it  could  not  be  tried 
in  her  case.  This  is  more  likely  to  be  the  result  if  the  amount 
of  food  taken  has  been  grossly  insufificient.  Notwithstanding, 
indirect  suggestion  frequently  fails,  and  in  such  instances  both 
the  physician  and  the  nurse  must  rely  upon  their  tact  and  per- 
suasion. It  is  unnecessary  to  add  that  in  making  an  agreement 
with  a  patient,  the  latter  must  be  rigidly  adhered  to.  Occa- 
sionally the  suggestion  that  the  patient  will  retain  the  food  if 
she  swallows  it  in  large  quantities  is  successful.  Of  course 
this  also  may  fail,  and  the  physician  may  be  forced  to  give  the 
patient  exceedingly  small  quantities,  and  in  such  physical  con- 
dition that  it  cannot  be  vomited;  e.g.,  thoroughly  hard-boiled, 
partially  dried  and  powdered  yolk  of  Q.gg,  bread  crumbs,  crack- 
ers, and  the  like.  Exceedingly  small  fragments  of  bacon  may 
be  added,  or  salt  judiciously  added.  Water  may  be  freely 
administered  by  high  enema  or  by  the  Murphy  drip. 

Other  articles  of  food  may  then  be  tried,  especially  milk. 
Exceedingly  small  quantities  only  should  be  attempted,  and 
repeated  at  frequent  intervals.  If  milk  is  rejected,  white  of 
eggs  or  albumin  water  may  be  tried.  Again,  the  milk  may  be 
modified  in  any  manner  to  suit  the  individual  case,  according 
to  the  judgment  of  the  physician.  If  a  beginning  can  be  made 
the  patient  w^ill  soon  retain  other  food,  such  as  finely  minced 
ham,  dried  beef,  minced  chicken,  steak,  and  the  like. 

If  there  be  marked  epigastric  tenderness,  it  may  be  wise 
to  omit  massage  of  this  region  for  some  time,  and  then  very 
gently  and  gradually  include  it. 

Usually  it  is  best  to  avoid  medicine,  as  this  also  will  be 
vomited.  However,  it  is  not  infrequently  found  that  bromids 
are  retained.  At  such  times,  20  grains  (1.3  Gm.)  of  ammon- 
ium bromid  with  a  little  aromatic  spirits  of  ammonia  and  pep- 
permint water  may  be  given,  well  diluted.  Again,  patients 
sometimes  do  well  under  the  influence  of  small  doses  of  mor- 
phin,  that  is  ^.o  of  a  grain  (O.CX)2  Gm.).  This  mav  be  repeated 
every  half-hour  until  yi  grain  (0  008  Gm.)  has  been  gi\cn. 
Larger  doses  may  be  used,  but  their  likelihood  to  produce  and 
make  worse  the  nausea  must  be  borne  in  mind.    The  morphin 


598  DISEASES    OF   THE    NERVOUS    SYSTEM. 

may  be  given  dissolved  in  water^  in  a  few  drops  of  brandy,  or 
in  a  teaspoonful  of  iced  champagne.  Sometimes  small  doses  of 
cocain  may  advantageously  be  substituted  for  the  morphin. 
Champagne  by  itself  we  have  not  found  to  be  very  successful 
in  relieving  anorexia  nervosa.  However,  sometimes  it  will  be 
retained  when  all  foods  fail.  Carbonated  waters  may  also 
prove  of  value. 

AMien  no  food  is  retained  for  several  days,  it  may  become 
necessary  to  resort  to  tube-feeding  by  the  nose  or  mouth. 
The  patient  may  complain  of  difficulty  of  swallowing.  It  is 
frequently  necessary  to  resort  to  this  expedient  but  once.  At 
other  times,  the  mere  preparation  for  the  feeding  is  often  suffi- 
cient to  stimulate  the  patient  to  retain  nourishment.  If  tube- 
feeding  fails,  it  is  well  to  precede  the  next  attempt  by  a  hypo- 
dermic injection  of  morphin,  ^  to  ^  grain  (0.008  to  0.016  Gm.) 
and  scopolamin  ^qo  to  %oo  grain  (0.00033  to  0.00065  Gm.).  This 
quiets  the  patient,  and  facilitates  retention.  At  other  times 
recourse  may  be  had  to  rectal  suppositories  of  opium.  Rectal 
feeding  also. may  be  resorted  to,  but  usually  proves  unsatisfac- 
tory. Besides,  its  use  may  confirm  the  patient  in  the  belief 
that  she  really  has  some  serious  affection  of  the  stomach. 

It  is  a  remarkable  fact  that  patients  suffering  from  anorexia 
nervosa  frequently  preserve  a  remarkable  appearance  of 
health  in  spite  of  the  persistent  rejection  of  food.  In  such 
instance  it  is  probable  that  food  is  being  taken  surreptitiously. 
In  other  instances,  however,  there  is  a  more  or  less  decided 
loss  of  weight. 

Rapid  breathing  in  hysteric  cases  is  usually  of  no  sig- 
nificance, and  as  a  rule  subsides  spontaneously.  Hysteric 
retention  of  urine  also  is  not  a  serious  complication.  Rupture 
of  the  bladder,  of  course,  never  occurs,  nor  even  a  dangerous 
distention.  Placing  the  patient  on  the  vessel,  and  having 
within  hearing  the  suggestive  sound  of  running  water,  the 
nurse  leaving  the  room  for  the  time  being,  is  often  efficacious 
in  inducing  the  patient  to  empty  the  bladder.  The  catheter 
is  rarely,  if  ever,  to  be  used.  Hysteric  anuria  is  to  be  treated 
by  the  administration  of  diuretics,  and  also  large  quantities  of 
liquids.  The  anuria  is  not  accompanied  by  alarming  symp- 
toms, and  is  frequently  only  simulated.  Hysteric  polyuria 
does  not  require  treatment. 


HYSTERIA.  599 

Insomnia  will  usually  improve  on  rest,  bathing,  full  feeding, 
but  if  it  is  necessary  to  resort  to  drugs,  the  bromids,  20  to  30 
grains  (1.3  to  2.0  Gm.),  are  the  most  useful,  or  luminal,  in 
doses  of  1^  to  3  grains  (0.1  to  0.2  Gm. ),  proves  very  efficacious. 
At  times  medinal  may  be  given,  in  5-  to  10-grain  (0.32  to  0.65 
Gm.)  doses.  As  a  rule,  however,  a  capsule  of  starch  or  some 
other  placebo,  accompanied  with  the  suggestion  that  it  will 
induce  sleep,  answers  the  purpose  admirably.  At  times  it  may 
be  wise  to  use  a  starch  capsule  on  alternate  nights.  Very  fre- 
quently the  use  of  warm  baths,  just  before  the  patient  retires, 
is  productive  of  good  results.  At  times,  too,  the  drip-sheet 
or  other  simple  form  of  hydrotherapy  is  beneficial. 

In  many  cases  of  hysteria,  a  systematic  rest  treatment  can- 
not be  carried  out,  and  in  such  cases  we  must  rely  upon  proper 
physiologic  methods  of  living,  together  with  suggestion.  In 
this  connection  it  is  important  to  remember  that  occupation, 
both  mental  and  physical,  is  of  the  greatest  benefit,  though 
many  hysteric  patients  are  disinclined  to  work,  especially 
those  whose  means  do  not  necessitate  it.  Success  here  largely 
depends  on  the  resourcefulness  of  the  physicians. 

Special  psychotherapeutic  measures  other  than  those  here 
outlined  are  not  indicated  in  hysteria.  Hypnotism  is  rarely 
justified  since  it  does  not  cure  the  underlying  condition; 
indeed,  it  emphasizes  the  susceptibility  to  suggestion  from 
which  the  patient  already  sufifers.  Psychanalysis  has  of  late 
years  attracted  considerable  attention.  It  has,  however^  never 
gained  a  secure  foothold  in  this  country,  and,  like  other  fads, 
is  again  disappearing.  It  is  a  common  experience  with  physi- 
cians— with  neurologists  and  practitioners  in  general — that  it 
is  of  the  utmost  benefit  to  allow  the  patient  to  give  a  full  and 
complete  account  of  his  case,  to  talk  himself  out  concerning 
his  symptoms,  their  history,  causes  and  allied  matters.  This 
fact  was  recognized  long  before  psychanal3'-sis  was  thought  of. 
Merely  in  the  course  of  the  patient's  story,  the  symptoms  lose 
in  the  patient's  mind  their  importance,  and  often  fade  away. 
There  is  a  sense  of  satisfaction  and  relief  in  having  told  the 
doctor  everything — in  unloading  everything,  as  it  were,  on  the 
doctor.  Hysteric  patients  do  not  do  well  unless  they  have 
gotten  into  close  touch  with  the  doctor,  and  have  acquired  full 
confidence  in  the  latter.     The  patient  is  then  in  a  position  to 


600  DISEASES   OF   THE    NERVOUS    SYSTEM. 

receive  the  greatest  possible  benefit  from  explanation,  advice, 
and  suggestion.  However,  to  inject  into  the  patient's  mind, 
as  do  the  psychanalysts,  thoughts  of  a  sexual  nature,  to  give 
to  every  symptom,  dream,  or  what-not  a  sexual  explanation, 
is  obviously  pernicious  and  harmful.  Indeed  much  injury  is 
sometimes  done  by  arousing  in  the  patient's  mind  ideas  of 
self-blame  and  sinfulness,  ideas  which  often  center  about 
sexual  transgressions  that  never  occurred,  or,  in  the  absence 
of  a  positive  history,  are  relegated  by  the  psychanalysts  to 
mythical  peccadillos  of  childhood. 

HYSTERIA    FOLLOWING    ACCIDENTS. 
"TRAUMATIC"    HYSTERIA. 

Our  views  concerning  the  nervous  manifestations  which 
not  infrequently  make  their  appearance  after  accidents  have, 
in  the  course  of  years,  undergone  a  radical  change.  This 
change  has  been  due  to  our  increasing  knowledge  of  hysteria. 
The  symptoms  observed  were  early  embraced  under  the  term 
"railway  spine."  Erichsen  made  use  of  the  term  "concussion 
of  the  spine."  Erichsen,  Leyden,  Westphal,  Erb,  and  others 
originally  believed  that  the  symptoms  were  due  to  a  chronic 
meningomyelitis,  multiple  foci  of  disease  in  the  cord  and  brain, 
and  other  organic  lesions.  No  evidence  was  forthcoming  from 
actual  observations  to  prove  the  correctness  of  these  views. 
Owing  to  the  fact  that  death  did  not  take  place — a  fact  the 
significance  of  which  was  not  at  the  time  recognized — cases  did 
not  come  to  autopsy.  However,  in  two  instances  in  which  the 
patients  died  of  intercurrent  afTections,  one  of  aneurism  and 
the  other  of  acute  alcoholism^  a  careful  microscopical  study  of 
the  brains  and  cords  by  Dercum,  in  1895,  failed  to  reveal  any 
lesions  whatever.  Moeli,  Wilks,  Walton  and  Putnam  pointed 
out  the  psychic  or  hysteric  nature  of  the  symptoms.  Thomsen 
and  Oppenheim,  while  admitting  the  hysteric  interpretation  of 
the  symptoms,  made  reservations  as  to  the  partial  existence  of 
organic  lesions,  but  Charcot  showed  that  the  symptoms  have 
no  anatomical  basis  whatever.  Charcot  pointed  out  that  the 
symptoms  are  exactly  the  same  as  can  be  produced  by  hyp- 
notic suggestion,  that  they  were  the  result  of  autosuggestion, 
and  finally  that  they  were  all  due  to  hysteria,  and  nothing-  but 


HYSTERIA    FOLLOWING   ACCIDENTS.  601 

hysteria.  Page  also  early  recognized  the  non-organic  char- 
acter of  the  symptoms.  It  is  a  significant  fact  that  the  terms 
"spinal  concussion"  and  "railway  spine/'  once  in  use  the  world 
over,  have  disappeared  from  the  courts  and  from  the  reports 
of  physicians  for  many  years  past.  Oppenheim  substituted 
for  them  the  expression  "traumatic  neuroses."  Unfortunately 
the  word  "neurosis,"  vague  and  indefinite  in  meaning,  failed  to 
convey  any  conception  as  to  the  nature  of  the  condition  pres- 
ent. Notwithstanding,  the  term  "traumatic  neuroses"  rapidly 
became  the  vogue.  Soon,  however,  the  hysteric  nature  of  the 
symptoms  became  more  and  more  evident,  and  the  expression 
"traumatic  hysteria"  came  to  be  used  as  a  substitute.  For  a 
long  time  the  profession  were  inclined  to  hedge  with  Oppen- 
heim, as  to  the  purely  hysteric  character  of  the  symptoms,  and 
such  terms  as  "traumatic  neurasthenia,"  and  hybrid  expres- 
sions as  "traumatic  hystero-neurasthenia,"  came  to  be  em- 
ployed, but  they  finally  gave  way  with  our  increasing  knowl- 
edge to  the  name  "traumatic  hysteria,"  and  thus  medical  men 
came  to  adopt  a  position  which  one  of  them,  Charcot,  had  long 
anticipated. 

As  we  have  seen  in  the  preceding  pages,  the  symptoms  of 
hysteria  have  their  origin  in  suggestion.  In  the  hysteria  ob- 
served in  accident  cases  the  same  fact  obtains.  The  sugges- 
tion may  have  its  inception  in  the  knowledge  of  having  passed 
through  an  accident,  re-enforced,  it  may  be,  by  fright,  or,  as  is 
most  frequently  the  case^  it  may  have  its  origin  in  the  pos- 
sibilities and  prospects  of  compensation.  Certain  it  is  that 
trauma  of  itself  never  causes  hysteria.  It  is  a  noteworthy  fact 
that  trauma  occurring  during  sleep,  during  surgical  anesthesia 
or  alcoholic  intoxication,  is  never  followed  by  hysteria.  Again, 
to  show  the  necessary  presence  of  suggestion,  we  need  only 
cite  the  well-known  fact  that  persons  injured  during  sports,  in 
gymnastic  exercises,  in  foot-ball,  never  develop  hysteria. 
Further  the  hysteria  in  a  given  case  following  an  accident  bears 
no  relation  to  the  character  or  the  degree  of  an  injury,  and  the 
surgeon  is  not  living  who  can  say  after  examining  a  bruise,  a 
dislocation,  or  a  broken  bone,  that  the  patient  will  also  sufifer 
from  hysteria.  Finally,  it  is  a  notorious  fact  that  quite  com- 
monly, even  when  the  hysteria  is  pronounced,  the  evidences  of 
injury  are  exceedingly  trivial,  such  as  a  small  abrasion  or  a 


602  DISEASES    OF   THE    NERVOUS    SYSTEM. 

trifling  bruise,  or  they  are  actually  non-existent  and  wholly 
imaginar}^ 

If  it  is  claimed  that  an  injury  must  in  addition  be  accom- 
panied by  fright  in  order  that  hysteria  may  supervene,  it  must 
be  remembered  that  fright  unaccompanied  by  any  injury  what- 
ever is  a  cause  of  hysteria.  Try  as  we  may,  no  role  can  be 
assigned  to  trauma,  and  the  expression  "traumatic  hysteria" 
so  frequently  and  so  glibly  used  by  medical  witnesses  in  the 
courts,  describes  a  condition  which  does  not  exist. 

How  gr^at  a  role  the  presence  of  the  right  to  recover  dam- 
ages plays  is  revealed  by  the  history  of  railway  accidents. 
Until  the  recent  enactment  of  workmen's  compensation  laws, 
traumatic  hysteria  was  an  affection  limited  to  passengers. 
Physical  injuries,  of  course,  were  found  in  locomotive  engi- 
neers, firemen,  brakemen  and  conductors,  but  hysteria  never. 
However,  when  the  right  to  recover  damages  is  present,  the 
immunity  of  railroad  employees  disappears.  For  instance,  in 
Germany,  where  a  system  of  workmen's  pensions  exists,  rail- 
road employees  form  a  not  inconsiderable  number  of  the  cases 
of  "traumatic"  hysteria,  and  often  prove  to  be  among  the  most 
persistent  of  the  pension  seekers. 

The  hysteria  observed  in  litigants  bears,  as  we  have  seen, 
no  relation  to  trauma;  neither  does  it  bear  any  relation  to 
fright.  Hysteria  evoked  by  fright  alone — i.e.,  hysteria  into 
which  compensation  does  not  enter — presents  a  very  different 
clinical  history  from  the  hysteria  of  litigation.  Fright  hysteria 
is  of  immediate  onset;  its  symptoms  supervene  at  once,  at  the 
time  the  fright  is  experienced,  and,  as  a  rule,  it  is  of  short 
duration,  and  rapidly  subsides.  When  it  does  not  rapidly  sub- 
side, or,  having  subsided,  recurs,  special  causes  are  at  work  to 
bring  about  its  prolongation,  and,  in  litigation  cases,  it  is  the 
prospect  of  compensation. 

In  the  hysteria  of  litigation  cases,  the  history  is  quite  com- 
monly that  the  supposedly  injured  person  is  attended  by 
bystanders,  conveyed  to  a  nearby  drug-store,  perhaps  sent  to 
a  hospital,  or  taken  to  his  home.  In  either  case  he  comes  under 
the  care  of  physicians.  Soon  a  lawyer  is  consulted,  medical 
experts  are  called  in,  elaborate  examinations  are  made.  How 
full  of  suggestion  such  examinations  are,  the  preceding  pages 
have  already  shown.     Elaborate  tests  are  made,  many  notes 


HYSTERIA    FOLLOWING   ACCIDENTS.  603 

are  taken,  strange  scientific  terms  are  used;  and  the  connec- 
tion, in  the  mind  of  the  patient,  that  he  has  been  seriously 
hurt  grows  steadily  in  strength,  and  with  this  his  proportionate 
expectation  in  the  amount  of  his  damages. 

At  times  it  does  not  occur  to  the  plaintifif  until  hours,  days, 
weeks,  and  even  months  have  elapsed  after  an  accident  that  he 
has  been  hurt.  In  short,  in  the  hysteria  presented  l)y  plain- 
tiffs, the  phenomena  observed  are  due  neither  to  trauma  nor 
to  fright,  but  to  litigation,  and  the  proper  designation  for  the 
condition  is  "litigation  hysteria." 

In  the  interval  pending  the  trial  and  final  settlement  of  the 
claim,  the  symptoms  resist  every  possible  form  of  treatment. 
This  is  an  absolutely  uniform  and  unvarying  experience.  It 
is  a  noteworthy  fact,  further,  that  if  an  expected  trial  be  not 
reached,  or  be  for  some  reason  postponed,  the  symptoms  be- 
come less  marked,  and  often  largely  subside  until  the  next  date 
of  trial  approaches,  when  they  again  become  more  pronounced ; 
fresh  examinations  are  made,  the  plaintiff  becomes  worse  than 
ever,  and  even  new  symptoms  make  their  appearance.  During 
all  of  the  period  pending  trial,  the  patient  continues  under 
inedical  care,  but  with  the  settlement  all  medical  attendance 
ceases;  the  symptoms  disappear,  the  patient  either  forgetting 
all  about  them  or  no  longer  making  a  voluntary  effort  to  main- 
tain them.  If,  however,  settlement  be  delayed,  the  plaintiff' 
neither  gets  well  nor  improves^  and  this  situation  may  con- 
tinue indefinitely,  sometimes  for  years,  as  long  as  any  hope  of 
settlement  persists  in  the  plaintiff's  mind.  The  plaintiff  knows 
that  the  success  of  his  claim  depends  upon  the  existence  and 
persistence  of  symptoms.  The  hysteria  of  accident  claimants 
thus  has  its  origin  in  the  psychology  of  compensation,  and 
nothing  is  of  avail  save  the  definite  disposal  of  the  claim  for 
or  against  the  plaintiff. 

In  closing,  we  must  remember  that  after  an  accident — e.g., 
a  collision — only  a  small  percentage,  perhaps  a  single  individ- 
ual, subsequently  develops  hysteria.  As  a  rule,  the  persons 
affected  reveal  in  their  histories — often  carefully  concealed, 
denied  or  perverted — a  previous  hysteria,  confirmed  in  char- 
acter, or  they  present  the  crass  evidence  of  the  underlying 
neuropathy  already  described  in  the  preceding  pages, 


604  DISEASES    OF   THE    NERVOUS    SYSTEM. 

THE    NEURASTHENOID    STATES 
(PSYCHASTHENIA). 

The  conditions  which  were  at  one  time  classed  under  the 
head  of  neurasthenic  insanities  have  been  termed  by  Janet 
collectively,  "psychasthenia."  Dercum  has  applied  to  them  the 
term,  the  "neurasthenoid  states."  There  are  here  present  two 
factors,  one  a  neuropathy  pre-existing-,  innate  and  usually 
hereditary,  upon  which  a  second  factor,  a  nervous  exhaustion, 
has  been  superimposed.  Because  of  this  pre-existing  neuro- 
pathy, the  symptoms  of  the  nervous  exhaustion  present  differ 
from  those  met  with  in  simple  neurasthenia;  for  example,  as  a 
result  of  nervous  exhaustion  an  individual  otherwise  normal 
may  suffer  from  an  attack  of  fear  such  as  has  already  been 
described.  The  attack  remains  generalized  in  character,  and 
subsides  without  any  special  features  being  developed.  How- 
ever, if  the  patient  be  previously  neuropathic,  a  pathological 
association  may  be  formed  in  his  mind,  so  that  the  emotion  of 
fear  becomes  definitely  linked  with  certain  relations  of  his 
environment.  Thus,  such  a  patient  having  a  spontaneous 
attack  of  fear  while  he  is  alone,  may  subsequently  be  afraid  of 
being'  alone,  i.e.,  he  acquires  a  monophobia.  All  of  the  symp- 
toms of  a  psychasthenia  are  susceptible  of  kindred  explana- 
tions. Weakness  of  will,  indecision  and  lack  of  inhibition  are 
natural  outgrowths  of  the  neuropathy  and  the  exhaustion.  A 
normal  neurasthenic,  because  of  his  fatigue,  loses  his  usual 
readiness  of  decision;  in  a  neuropathic  neurasthenic  this 
indecision  may  become  so  pronounced  as  to  lead  to  a  true 
insanity  of  indecision,  a  folie  dii  doute.  In  a  case  of  simple 
neurasthenia,  the  will-power  of  the  patient  may  be  lessened, 
but  in  a  neuropathic  patient  the  will  may  be  so  weakened  that 
he  becomes  unable  to  perform  comparatively  simple  and  ordi- 
nary acts ;  thus  a  clergyman  may  be  unable  to  mount  the 
steps  to  his  pulpit.  Such  a  symptom  is  termed  abulia. 
Again,  the  simple  neurasthenic  has  impaired  self-control, 
becomes  irritable,  his  impulses  are  not  controlled  as  in  health ; 
but  this  deficiency  of  self-control  in  the  neuropathic  neuras- 
thenic may  give  rise  to  special  gestures,  exclamations,  words 
or  phrases  which  the  patient  is  unable  to  inhibit ;  i.e.,  such  a 
patient  may  develop  psychomotor  tics,  or  tic  convulsif,  as  it 


THE    NEURASTHENOID    STATES.  605 

has  been  termed  by  the  French.  These  movements  may  con- 
sist of  bowing  or  of  bizarre  gestures,  or  the  patient  may  sud- 
denly utter  disconnected  phrases,  oaths  and  obscene  expres- 
sions. Inhibition  having  broken  down,  the  symptoms  tend  to 
become  in  time  confirmed  and  established. 

The  neurasthenoid  states,  the  psychasthenias,  do  not  as  a 
rule  ofl:'er  an  encouraging  prognosis.  However,  all  means  at 
our  command  for  raising  the  general  health  of  the  patient  to 
the  highest  possible  level  should  be  instituted.  It  is  significant 
and  important  also  to  remember  that  many  psychasthenic 
persons  undergo  spontaneous  improvement,  or  have  more  or 
less  prolonged  periods  of  remission.  Others  again  improve  as 
they  grow  older,  especially  is  this  true  as  middle  age  is 
approached. 

In  recent  cases,  full-rest  methods  with  hyperfeeding,  mas- 
sage, bathing,  exercise,  gradual  retraining,  and  re-education 
yield  most  gratifying  results.  If  a  tic  be  present,  systematic 
exercises  with  difficult  or  complex  movements  necessitating 
careful  muscular  co-ordination  and  concentration  of  will  and 
attention  are  often  of  value.  However,  in  long-standing  cases 
little  can,  as  a  rule,  be  achieved. 

Psychotherapy  may  also  be  used  in  like  manner  as  in 
hysteria,  though  in  cases  of  psychasthenia  the  results  are  not 
as  satisfactory.  Occasionally  if  the  patient  is  able  to  recall  the 
full  details  of  the  first  occurrence  of  a  special  fear  or  other 
symptom,  the  pathological  association  formed  at  the  time  may 
be  broken  up ;  i.e.,  it  may  be  explained  away.  If  such  a  result 
is  possible,  it  can  as  a  rule  be  achieved  in  a  single  interview. 
It  does  not,  as  stated  by  the  psychanalysts,  require  upward  of 
three  years  of  daily  interviews  and  questionings,  nor  is  it 
necessary  to  search  for  imaginary  or  forgotten  sexual  trans- 
gressions. 

It  is  an  interesting  fact  that  a  certain  number  of  psychas- 
thenics present  the  symptoms  of  hypothyroidism ;  especially 
are  they  noted  in  cases  presenting  marked  indecision  and 
abulia.  In  a  few  cases  actual  myxedemoid  symptoms  are 
present.  In  these  conditions  small  doses  of  thyroid  extract, 
given  over  a  long  period  of  time  are  of  value, 


606  DISEASES    OF    THE    NERVOUS    SYSTEM. 

HYPOCHONDRIA. 

Hypochondria  is  a  nervous  affection,  almost  equal  in  impor- 
tance to  neurasthenia  or  hysteria,  although  less  frequently 
met  with.  Occasionally  it  has  been  confounded  with  these 
aft'ections.  Medical  writers  on  the  whole  have  been  loath  to 
grant  to  hypochondria  a  definite  position  in  our  nosology,  and 
for  the  reason  that  hypochondriacal  states  may  occur  in  other 
affections  such  as  the  prodromal  periods  of  melancholia  or 
paranoia,  or  may  complicate  other  mental  diseases.  However, 
hypochondria  presents  a  characteristic  clinical  picture.  Its 
symptoms  owe  their  origin  to  a  change  in  the  general  sense  of 
bodily  well-being,  a  change  which  gives  rise  to  a  more  or  less 
fixed  conviction  of  bodily  illness.  The  patient  usually  seeks 
for  an  explanation  in  the  disease  of  one  or  more  organs.  The 
most  careful  clinical  examination,  however,  fails  to  reveal  any- 
thing of  moment.  Hereditary  factors  are  very  commonly 
found  in  the  family  history.  Hypochondria  occurs  more  fre- 
quently in  men  than  in  women,  more  frequently  in  single  than 
in  married  persons,  and  more  frequently  before  40  than 
afterward. 

Hypochondria  is  a  neuropathy  which  has  as  its  expression 
a  constitutionally  diseased  personality. 

The  patient  is  much  concerned  in  regard  to  his  health. 
Frequently  he  is  chronically  afraid  of  catching  cold,  or  of  some 
serious  affection  of  the  chest.  In  such  case  he  may  wear  an 
excessive  amount  of  clothing.  Frequently,  too,  he  is  peculiar 
regarding  his  food.  At  one  time  he  eats  an  excessive  amount 
of  meat,  at  others  he  is  a  vegetarian.  At  one  time  he  diets 
himself  so  rigidly  that  he  takes  too  little  nourishment,  at 
others  he  eats  excessively. 

He  may  complain  of  various  vague  sensations,  such  as 
pains  in  the  head  or  about  the  heart,  trembling  of  the  stomach 
or  intestines,  numb  sensations,  distress  or  pain  referred  to 
some  special  organ,  such  as  the  liver,  or  it  may  be  the  genitals. 
At  times  also  he  speaks  of  burning  sensations  in  the  mucous 
membranes,  of  strange  feelings  in  the  skin  or  hair.  Physical 
examination  always  yields  a  negative  result.  Occasionally 
there  is  present  a  slight  atonic  indigestion  and  constipation ; 
perhaps  at  others  coldness  or  slight  lividity  of  the  hands  and 


HYPOCHONDRIA.  607 

feet.  The  symptoms  are,  however,  always  trivial  and  of  little 
consequence. 

The  patient  notes  his  condition  very  carefully,  and  fre- 
quently observes  his  bowel  movements  or  urine  in  great  detail. 
Very  often  he  keeps  a  record  of  his  symptoms,  and  in  the  con- 
sultations with  his  physician  frequently  produces  little  pieces 
of  paper  upon  which  he  has  made  numerous  notes.  Quite 
commonly  he  gives  an  account  of  having  visited  numerous 
physicians,  remembers  the  various  diagnoses  that  have  been 
made  in  his  case,  declares  that  none  of  his  physicians  have 
benefited  him,  and,  of  course,  believes  himself  to  be  a  very  sick 
man.  Occasionally  he  reads  medical  books  or  quack  literature, 
and  goes  to  the  physician  with  the  diagnosis  of  his  disease 
already  made.  He  is  almost  always  taking  medicine  of  some 
kind,  and  when  he  believes  he  is  not  obtaining  proper  treat- 
ment from  physicians,  treats  himself.  The  shelves  and  closets 
of  his  room  are  usually  filled  with  medicine  bottles. 

Hypochondria  does  not  always  pursue  an  even  course. 
Ideas  of  ill-health  are  at  times  less  pronounced,  and  actual 
remissions  may  occur.  In  quite  a  large  number  of  cases  the 
disease  fades  with  advancing  years. 

Other  things  equal,  the  prognosis  is  most  unfavorable,  when 
a  neuropathic  family  history  is  pronounced.  Further,  the 
hypochondria  of  youth  offers,  on  the  whole,  a  more  favorable 
outlook  than  the  hypochondria  which  makes  its  appearance  in 
adult  life.  The  prognosis  as  to  the  lucidity  of  the  patient  is 
uniformly  good.  The  patient's  mind  remains  clear ;  dementia 
is  not  established. 

In  addition  to  a  hypochondria  general  in  its  character,  we 
may  distinguish  two  special  forms,  namely,  the  gastro-intes- 
tinal  form  and  the  sexual  form.  In  the  first  some  slight  but 
real  digestive  disturbance  may  be  present ;  in  the  second  form, 
which  is  more  common  in  young  men,  there  is  frequently  a 
belief  or  fear  of  impotence,  associated  perhaps  with  a  history 
of  masturbation  or  of  seminal  emissions.  Very  often  these 
patients  are  about  to  marry.  As  a  rule,  real  impotence  does 
not  exist,  though  every  now  and  then  fear  and  nervousness 
and  the  belief  in  impotence  lead  to  failure. 

The  indications  for  treatment  are  not  so  clear  as  in  neuras- 
thenia or  hysteria.     It  does  little  good  to  tell  the  patient  his 


608  DISEASES    OF   THE    NERVOUS    SYSTEM. 

trouble  is  imaginary,  but  we  should  examine  the  patient  thor- 
oughly, point  out  to  him  the  absence  of  organic  disease,  and 
the  purely  functional  character  of  the  symptoms.  Such 
patients  like  to  be  examined,  and  a  properly  conducted  exami- 
nation will  beget  confidence  in  the  physician.  However,  they 
are  but  little  influenced  by  sug-gestion.  The  general  health 
should  be  maintained  at  as  high  a  level  as  possible,  by  atten- 
tion to  hygiene  and  physiologic  living.  This  being  accom- 
plished, the  patient  should,  if  possible,  be  kept  at  work.  The 
work  should  be  such  as  to  keep  his  time  well  filled,  and  to  give 
him  but  little  time  to  dwell  upon  his  troubles.  It  is  found  that 
these  patients  usually  enjoy  the  best  health  when  working  the 
hardest.  Hydrotherapy,  electricity  and  massage  may  be  used, 
but  care  must  be  taken  not  to  develop  in  the  mind  of  the 
patient  the  idea  that  his  symptoms  are  serious. 

HEADACHE. 

Headache  is,  of  course,  a  symptom  and  not  a  disease. 
However,  it  is  such  an  important  symptom,  and  the  dominant 
feature  in  so  many  afifections,  that  it  requires  special  con- 
sideration. 

Headache  is  either  organic  or  functional.  Organic  head- 
ache is  associated  with  structural  disease  of  the  cranial  con- 
tents, e.g.,  brain  tumor,  is  continuous,  and  is  associated  with 
sleep  disturbances,  vomiting  and  gros-s  physical  signs  of 
disease.  Syphilitic  headaches  are,  of  course,  associated  with 
a  specific  history  and  other  symptoms  of  syphilis.  They  are 
usually  more  pronounced  at  night. 

Functional  headaches  may  be  classified  as  follows :  first, 
headache  associated  with  the  great  neuroses,  neurasthenia  and 
hysteria;  second,  headaches  of  diathetic,  toxic  and  infectious 
origin ;  third,  headache  associated  with  affections  of  the 
special  sense  organs,  such  as  the  eyes  and  the  various  viscera; 
and,  fourth,  headache  associated  with  various  diseases  of  the 
blood. 

Neurasthenic  Headache.  Here  the  pain  is,  as  a  rule,  dull 
and  diffuse,  and  suggests  fatigue.  It  may  even,  when  pro- 
nounced, quickly  disappear  upon  rest.  As  a  rule,  it  is  not 
diffused  over  the  entire  head,  but  is  located  in  the  occiput  and 


HEADACHE.  609 

in  the  upper  part  of  the  neck,  or  over  the  frontal  region,  or  just 
above  the  eyes.  Occasionally  the  pain  is  referred  to  the 
temples  and  parietal  region,  but  occipital  pain  is  the  most  fre- 
quent. The  pain  is  often  accompanied  by  a  feeling  of  pressure 
or  constriction  (a  feeling  of  a  tight  band  about  the  head),  or  is 
associated  with  pressure  and  drawling  sensations  at  the  back 
of  the  neck.  Other  sensations,  such  as  heaviness  and  throb- 
bing, are  sometimes  described. 

The  patient  presenting  neurasthenic  headache  presents  in 
addition  all  of  the  cardinal  symptoms  of  neurasthenia,  and  the 
diagnosis  of  course  resolves  itself  into  the  recognition  of  the 
underlying  neurasthenia.  Its  treatment  is  the  treatment  of 
neurasthenia,  and  the  reader  is  referred  to  the  section  on  this 
subject. 

Hysteric  Headache.  This  form  of  headache  is  found 
more  frequently  in  women.  The  patient  complains  in  terms 
which  suggest  exaggeration,  while  her  appearance  does  not 
convey  the  idea  of  serious  suffering.  If  asked  to  indicate  the 
seat  of  the  pain,  she  is  apt  to  point  to  a  small  area,  often  a  spot, 
which  can  be  definitely  covered  with  the  tip  of  the  finger.  She 
usually  describes  the  pain  as  deep  or  boring,  as  though  a  nail 
were  being  driven  into  the  head ;  it  is  this  symptom  which  has 
given  rise  to  the  term  clavus  hystericus.  On  examination  this 
area  is  found  like  the  other  sensory  stigmata  of  hysteria  to  be 
sensitive  to  superficial  pressure.  Other  symptoms,  such  as 
ringing  or  throbbing  noises  in  the  ears,  and  various  bizarre  sen- 
sations, may  also  be  complained  of.  Hysteric  clavus  is,  of 
course,  of  no  more  significance  than  the  hyperesthesia  noted 
beneath  the  breasts,  over  the  groins,  over  the  sternum  or  over 
the  spine.  The  treatment  of  hysteric  headache  is,  of  course, 
the  treatment  of  hysteria. 

Diathetic  Headache.  Patients  who  are  afflicted  with  a 
gouty  or  rheumatic  diathesis  frequently  suffer  from  headache. 
The  presence  of  the  other  symptoms  of  these  affections  estab- 
lishes the  diagnosis.  Diathetic  headaches  occur  more  fre- 
quently in  persons  of  middle  life.  Hereditary  factors,  too,  are 
sometimes  present. 

Headache  may  of  course  be  a  symptom  of  uremia,  the 
recognition  of  which  needs  to  be  prompt.  Headache  due  to 
uremia  may  be  most  pronounced  in  the  back  of  the  head  and 

39 


610  DISEASES    OF   THE    NERVOUS    SYSTEM. 

neck,  though  it  may  be  frontal.  Dizziness  is  often  present,  and 
the  patient  is  dull  and  apathetic.  The  headache  of  diabetes 
may  precede  the  onset  of  diabetic  coma,  but  it  is  rather  an 
infrequent  symptom. 

Toxic  Headaches.  Among  the  causes  of  headache,  chronic 
alcoholic  poisoning  should  be  borne  in  mind.  The  pain  com- 
plained of  is  usually  diffuse,  dull  in  character,  and  most  pro- 
nounced in  the  frontal  region.  It  is  usually  most  marked  in 
the  morning,  and  is  increased  by  the  additional  drinking  of 
alcohol.  Associated  with  the  headache  are  the  other  signs  of 
alcoholism.  Among  the  less  frequent  causes  of  headache,  lead 
poisoning  should  be  considered.  Headache  due  to  lead  is  pro- 
dromal to  or  associated  with  other  cerebral  symptoms,  such 
as  convulsions,  delirium  and  stupor.  Optic  neuritis  may  also 
be  present.  In  searching  for  the  obscure  cause  of  a  headache, 
the  abuse  of  tea,  coffee,  and  tobacco  must  also  be  kept  in 
mind.  Care  should  be  taken,  howe-ver,  not  to  confuse  these 
headaches  with  migraine.  Tobacco  headaches  occur  irregu- 
larly and  usually  bear  a  clear  relation  to  excessive  smoking. 

Headaches  from  Infection.  Headaches  associated  with  the 
various  acute  infectious  diseases  do  not  require  special  consid- 
eration ;  they  are  found  as  parts  of  well-known  symptom  groups. 

Headaches  symptomatic  of  affections  of  the  special  sense 
organs,  such  as  the  eye  and  the  various  viscera,  are  very 
important.  The  most  frequent  of  these  headaches  is  that  due 
to  eye-strain.  Usually  there  is  here  an  associated  condition  of 
nervous  exhaustion,  so  that  any  unusual  effort  is  followed  by 
a  headache.  The  eye-muscles,  like  other  muscles,  are  readily 
fatigued  in  neurasthenia,  and  it  is  not  surprising  that  the  use 
of  the  eyes  produces  headache,  especially  when  some  refractive 
error  such  as  astigmatism  or  hypermetropia  necessitates  a 
special  effort  at  accommodation.  Such  a  patient  usually  sleeps 
well,  and  rises  in  the  morning  free  from  headache.  About  the 
middle  of  the  day,  however,  or  after  the  eyes  have  been  used 
for  a  few  hours,  the  headache  comes  on,  and  frequently  inter- 
rupts the  patient's  work.  Rest  relieves  the  pain.  The  latter 
may  be  either  frontal  or  occipital  in  distribution,  more  fre- 
quently the  latter. 

In  the  treatment  of  eye-headaches,  it  is  important  of  course 
that  the  eyes  be  corrected,  but  while  this  may  relieve  it  may 


HEADACHE.  611 

fail  to  cure  the  headache.  The  underlying  neurasthenia 
demands  attention,  and  its  efficient  treatment  may  be  the  only 
means  of  elTecting'  a  permanent  result. 

Disease  of  the  nasal  chambers  or  sinuses  may  lead  to  head- 
ache referred  to  the  brow,  the  temples,  or  the  malar  regions. 
In  most  of  thes^  cases  the  symptoms  referable  directly  to  the 
nose  or  sinuses  are  so  clear  as  to  establish  the  diagnosis.  At 
times,  however,  the  local  symptoms  are  slight,  and  the  cause  of 
the  headache  may  be  overlooked  unless  especially  sought  for. 
In  all  obscure  cases  of  headache,  the  nose  and  its  accessory 
sinuses  should  be  thoroughly  examined. 

Headaches  are  also  produced  by  functional  disturbances  of 
the  stomach  and  intestines.  Such  headaches  are  usually 
present  when  signs  of  indigestion  are  most  marked ;  the  pain 
is  frequently  relieved  by  vomiting.  The  headache  is  probably 
caused  by  the  absorption  of  toxic  materials  from  the  stomach 
or  intestine.  The  treatment  is,  of  course,  the  treatment  of  the 
underlying  digestive  disturbance. 

Disease  of  the  uterus  and  ovaries  is  at  times  accompanied 
by  headache.  The  pain  is  usually  referred  to  the  vertex,  and 
may  be  temporarily  relieved  by  pressure.  The  patient  presents 
the  well-marked  symptoms  of  pelvic  disease,  and  nearly  always 
suffers  from  an  associated  symptomatic  neurasthenia. 

Headache  Due  to  Anemia  and  Hyperemia  of  the  Brain  and 
Diseases  of  the  Blood.  A  generation  ago  it  was  quite  common 
to  attribute  headache  to  anemia  and  hyperemia  of  the  brain. 
It  is  very  doubtful,  however,  whether  these  conditions,  when 
present,  play  any  role.  Thus  in  acute  general  anemia,  e.g., 
from  hemorrhage,  there  is  doubtless  also  an  anemia  of  the 
brain,  but  the  symptoms  are  dizziness,  faintness,  nausea,  vomit- 
ing, tinnitus,  failing  vision  and  perhaps  unconsciousness,  with 
dilatation  of  the  pupils;  at  no  time  does  the  patient  complain 
of  headache.  Again,  in  chronic  anemia,  as  from  repeated 
hemorrhages,  or  in  disease  of  the  blood  in  which  the  hemo- 
globin is  greatly  reduced — e.g.,  pernicious  anemia — weakness, 
dizziness,  apathy  and  somnolence  may  be  prominent  symptoms, 
but  seldom  does  the  patient  complain  of  headache.  On  the 
other  hand,  cerebral  hyperemia,  though  it  may  plav  a  role, 
cannot  be  considered  as  an  independent  cause  of  headache. 
Thus,  cerebral  hyperemia  probably  occurs  during  febrile  con- 


612  DISEASES    OF   THE    NERVOUS    SYSTEM. 

ditions,  but  the  associated  headache  is  probably  only  in  part 
due  to  this  cause.  Again,  a  plethoric  person  indulging  in  a  full 
meal,  and  especially  alcohol,  may  become  flushed  in  the  face, 
and  it  is  reasonable  to  infer  that  the  brain  is  also  hyperemic. 
Such  a  patient  may  complain  of  throbbing  in  the  temples, 
dizziness,  fullness  in  the  head  and  headache.  Further,  hyper- 
emia, without  doubt,  occurs  passively  in  venous  obstruction, 
as  in  mitral  stenosis,  but  headache,  if  present,  is  clearly 
secondary  in  its  origin. 

Clearly  anemia  and  hyperemia  of  the  brain  play  either  no 
or  a  very  doubtful  role  in  the  production  of  headaches;  and  it 
is  significant  that  after  neurasthenia  became  more  fully  under- 
stood these  diagnoses  were  but  rarely  made. 

MIGRAINE. 

Migraine  is  an  aiTection  characterized  by  irregularly  re- 
curring attacks  of  headache,  the  pain  being  usually  lim- 
ited to  or  most  marked  on  one  side  of  the  head ;  hence 
the  name  semi-crania.  The  pain  is  frequently  accom- 
panied by  nausea  and  vomiting,  various  paresthesias  and  visual 
disturbances. 

The  disease  rarely  begins  after  30  years  of  age.  It  may 
attack  young  children,  but  most  frequently  has  its  origin  dur- 
ing the  period  of  adolescence.  Heredity  appears  to  play  a  part 
in  the  etiology ;  it  frequently  occurs  in  the  same  family  for 
two  or  more  generations,  and  several  members  of  the  same 
generation  may  be  affected.  Excessive  mental  work,  poor 
physical  condition,  and  various  reflex  disturbances,  as,  for 
example,  eye-strain,  appear  to  have  an  influence  in  inducing 
attacks  of  migraine.  Indiscretion  in  diet,  the  abuse  of  alcohol 
and  tobacco,  tea,  and  coffee,  also  favor  attacks  in  those 
predisposed. 

An  apparent  relation  of  migraine  to  epilepsy  has  been 
pointed  out.  It  has  been  suggested  that  migraine  is  a  sensory 
equivalent  of  epilepsy.  However,  when  we  consider  that 
epilepsy  is  a  condition,  and  not  a  disease  entity,  that  many 
families  present  individuals  afflicted  with  migraine  but  not 
with  epilepsy,  and  we  realize  that  the  epilepsies  are  very  varied 
in  origin,  the  relation  of  migraine  to  epilepsy  becomes  very 


MIGRAINE.  613 

doubtful.  Even  in  individual  instances,  themselves  very  infre- 
quent, the  relation  is  at  most  only  casual. 

Patients  are  frequently  aware  for  several  hours  that  an 
attack  is  coming  on.  They  may  complain  of  weariness  and 
exhaustion,  or  of  heaviness,  fullness  or  pressure  in  the  head, 
sometimes  of  dizziness.  Frequently  the  digestion  is  dis- 
turbed. Many  patients  preceding-  the  attack  note  bright 
quivering  lines  or  bright  colors,  visual  scotomata,  occupying 
a  part  of  the  visual  field.  At  times,  a  hemianopsia  is  simulated. 
Some  cases  complain  of  tinnitus,  while  others  present  pares- 
thesia, most  frequently  a  numbness  or  pricking  involving  one 
side  of  the  face,  part  of  an  extremity,  or  it  may  be  the  entire 
half  of  the  body.  At  times,  also,  though  infrequently,  these 
symptoms  may  be  accompanied  by  disturbances  of  motion, 
especially  in  face  and  tongue,  so  that  the  patient  may  not 
speak  with  his  usual  distinctness. 

Vasomotor  and  pupillary  disturbances  may  also  be  present; 
the  face  on  the  side  affected  may  at  first  be  flushed,  and  later 
pale ;  the  pupil  may  be  at  first  contracted,  and  later  dilated. 
Nausea  and  vomiting  not  infrequently  occur.  Sometimes  the 
pain  is  relieved  by  the  vomiting;  at  other  times  it  is  accen- 
tuated. The  patient  is  usually  very  sensitive  to  light  and 
noises.  Motion  or  jarring  of  the  head  commonly  greatly 
increases  the  pain. 

TREATMENT. 

First,  the  general  health  of  the  patient  should  be  brought 
to  as  high  a  level  as  possible.  Great  attention  should  be  given 
to  dietary  and  hygienic  measures.  Mau}^  of  the  patients  are 
in  general  ill-health ;  and  rest  methods,  either  partial  or  com- 
plete, should  be  carried  out  whenever  possible.  (See  page  583.) 
As  in  neurasthenia,  the  diet  must  be  modified  so  as  to  reduce 
the  starches'  and  sugars  very  decidedly.  The  same  is  true  of 
the  red  meats.  The  white  meats,  chicken  and  fish,  eggs,  milk, 
and  the  succulent  vegetables  are  to  be  allowed  freely.  Milk  is 
a  very  important  article  of  diet,  and  severe  cases  often  do  well 
on  rest  and  a  diet  limited  to  milk  for  a  time.  Further,  it  is 
highly  nutritious,  and  at  the  same  time  favors  elimination. 
Milk*  is  of  special  value  because  it  contains  no  nuclein,  and 
therefore  cannot  lead  to  the  formation  of  uric  acid  or  other 


614  DISEASES    OF   THE    NERVOUS    SYSTEM. 

leucomaines.  Water  is  to  be  taken  freely  at  all  times.  The 
skin  should  be  kept  active  by  warm  sponge  bathing.  General 
massage  is  also  employed  with  advantage. 

Indigestion  is  to  be  guarded  against  as  far  as  possible. 
Constipation  should  be  corrected  by  simple  laxatives,  such  as 
stimulate  elimination,  e.g.,  sodium  phosphate.  At  times  cas- 
cara  is  useful.  Enemas  may  occasionally  be  used,  but  should 
not  be  instituted  as  a  routine  procedure.  Occasionally  a  brisk 
saline  cathartic  taken  in  the  very  beginning  cuts  short  an 
attack.    Intestinal  antiseptics  do  little  good. 

Great  benefit  is  often  derived  from  the  free  and  rather  pro- 
longed administrations  of  the  salicylates.  Ten  grains  (0.65 
Gm.)  of  sodium  salicylate  together  with  20  grains  (1.30  Gm.) 
of  sodium  bromid,  given  well  dissolved,  three  times  daily 
after  meals  often  influences  the  migraine  decidedly.  Aspirin 
when  well  tolerated  is  often  of  the  greatest  value.  Salophen, 
more  readily  and  easily  tolerated,  is  not  so  efficient. 

The  treatment  of  the  individual  attack  itself-  must  also  be 
considered.  In  severe  cases,  as  soon  as  the  prodromal  symp- 
toms make  their  appearance,  a  full  dose  of  salts  or  laxative 
water  should  be  administered.  Later  bromids,  preferably  am- 
monium bromid,  should  be  given  in  a  dose  of  30  grains  (1.9 
Gm.j.  The  patient  should  He  down  and  try  to  sleep,  the  room 
being  darkened.  In  cases  of  less  severity,  or  if  the  patient's 
engagements  are  such  that  he  must  if  possible  meet  them,  one 
of  the  coal  tar  products,  antipyrin  or  phenacetin,  3,  5,  or  10 
grains  (0.20,  0.30,  or  0.65  Gm.),  with  or  without  ^  or  1  grain 
(0.032  or  0.065  Gm.)  of  caffein,  may  be  given,  often  with  the 
very  best  result.  Sometimes  5  or  10  grains  (0.32  or  0.65  Gm.) 
of  aspirin  answer  equally  well.  Of  especial  service,  however, 
the  writers  have  found  cannabis  indica.  The  patient  is  in- 
structed to  take  1  drop  (0.06  mil)  of  the  fluidextract  every 
half-hour  until  some  relief  is  obtained.  If  1  drop  is  insufficient, 
2,  3  or  more  can  be  given.  Thus  the  dose  required  to  control 
an  attack  can  readily  be  determined.  Most  patients  are  re- 
lieved by  a  small  initial  dose,  but  sometimes  it  is  necessary  to 
increase  the  dose  to  5  or  10  drops  (0.3  or  0.6  mil),  or  even  more, 
to  relieve  the  patient.  The  patient  should  be  informed  as  to 
the  physiologic  action  of  the  drug  in  full  doses — the  dizziness, 
confusion  and  disturbances  in  the  sense  of  time  that  may  pos- 


VERTIGO.  615 

sibly  make  their  appearance.  These  symptoms,  alarming  to 
the  patient,  are  of  very  little  significance.  Cannabis  indica  has 
the  great  advantage  of  never  causing  depression,  and  of  never 
leading  to  a  drug-habit.  Sometimes  it  fails,  due  usually  to  an 
inefficient  preparation.  In  such  case  we  may  be  obliged  to 
have  recourse  to  gelsemium.  This  should  be  cautiously  admin- 
istered in  a  similar  manner.  It  is,  however,  less  efficient,  and 
the  fact  that  in  full  doses  it  is  both  a  nervous  and  cardiovas- 
cular depressant  should  be  borne  in  mind. 

The  drug  which  above  all  others  has  the  power  to  relieve 
pain  is,  of  course,  morphin;  but  the  fact  that  in  a  disease  with 
recurrent  attacks,  such  as  migraine,  it  leads  sooner  or  later  to 
the  formation  of  the  morphin  habit,  makes  it  inadmissible. 
Physiologic  methods  of  living,  proper  regulation  of  the  diet, 
relief  from  excessive  work  and  nerve-strain,  together  with  the 
general  up-building  of  the  patient,  and  combined  with  the 
thorough  use  of  salicylates  and  bromids,  will  bring  the  attacks 
under  measurable  control,  so  that  recourse  to  analgesic  reme- 
dies will  become  less  necessary. 

VERTIGO. 

Vertigo  is  a  symptom  in  which  the  patient  is  conscious  of 
a  disturbance  of  his  equilibrium;  there  is  a  subjective  sense 
of  movement,  or  of  actual  movement,  accompanied  by  a  more 
or  less  marked  disturbance  in,  or  even  loss  of,  the  sense  of 
space  relations.  This  disturbance  the  mind  translates  into  an 
illusion  of  turning  or  rotation.  This  movement  may  be 
referred  by  the  patient  to  his  own  person,  or  may  be  projected 
by  him  to  the  external  world ;  i.e.,  the  patient  may  experience 
a  sensation  as  though  he  himself  were  turning,  or  as  though 
the  objects  about  him  were  turning;  hence  the  term  vertigo, 
derived  from  the  verb  verterc,  to  turn.  The  terms  giddiness 
and  dizziness  are  both  commonly  applied  to  the  less  marked 
conditions  of  vertigo,  or  to  forms  that  are  so  slight  as  to  be 
almost  if  not  entirely  subjective. 

Vertigo  is  a  symptom  which  is  found  in  a  great  variety  of 
conditions ;  only  at  times  does  it  appear  as  an  independent 
clinical  affection ;  more  frequently  it  is  purely  symptomatic. 
It  may  be  a  symptom  of  a  general  affection  such  as  neuras- 


616  DISEASES    OF   THE    NERVOUS    SYSTEM. 

thenia  or  hysteria.  It  may  be  met  with  in  toxic  states,  e.g., 
those  due  to  alcohol,  tobacco  and  coffee ;  in  uremia  and  in  the 
early  periods  of  the  infectious  fevers.  It  may  be  met  with  in 
disturbances  of  the  digestive  tract  and  of  the  circulatory  appar- 
atus. It  may  be  met  with  in  disturbances  of  special  sense 
organs,  such  as  the  eye,  and  especially  the  ear.  In  the  eye  it 
may  be  due  to  a  refractive  error  or  a  loss  of  muscle  balance. 
In  the  ear  it  may  be  due  to  disturbances  of  the  semicircular 
canals  or  of  other  portions  of  the  auditory  apparatus.  Again, 
it  may  be  due  to  organic  brain  disease,  more  especially  of  the 
cerebellum  or  its  peduncles.  Finally,  cases  are  met  with  in 
which  no  cause  can  be  discovered. 

That  vertigo  may  be  excited  artificially  is  known  to  every 
child  who  tries  the  experiment  of  turning  rapidly  around  a 
number  of  times  in  succession.  The  vertiginous  sensations  of 
sea-sickness  have  doubtless  an  origin  in  a  similar  disturbance 
of  the  sense  of  space  relations.  Again,  vertigo  may  be  excited 
by  douching  the  ear  with  water,  or  by  the  passage  of  a  gal- 
vanic current  through  the  ears.  This  so-called  galvanic  ver- 
tigo is  remarkable  for  the  fact  that  the  person  experimented 
upon  tends  to  fall  toward  the  anode  on  the  closure  of  the  cur- 
rent, and  toward  the  cathode  on  the  opening  of  the  current. 

In  every  case  of  vertigo,  the  important  matter  is  the  diag- 
nosis as  to  cause.  As  may  be  inferred,  this  is  by  no  means 
always  possible.  If  the  vertigo  be  clearly  objective,  and  if  the 
signs  of  organic  brain  disease  be  present,  much  information 
may  be  gained  as  toi  the  site  of  the  lesion  by  the  Barany  tests. 
This  depends  upon  the  fact  that  in  vertigo  induced  by  rotation, 
or  by  douching  the  ear,  the  symptoms  are  accompanied  by 
nystagmus.  Nystagmus,  however,  can  only  take  place  pro- 
vided that  the  inferior  longitudinal  fasciculus,  which  connects 
the  nucleus  of  Deiters  with  the  nuclei  of  the  eye-muscles,  is 
open  and  intact.  It  is  very  clear  that  when  the  associated 
nystagmus  is  absent  or  deficient,  the  lesion  must  lie  in  this 
tract,  or  at  least  that  it  is  cerebral  and  not  cerebellar.  On  the 
other  hand,  if  it  be  not  interfered  with,  and  there  are  other 
signs  of  organic  brain  disease,  the  inference  is  obvious  that  the 
lesion  is  cerebellar  or  peduncular.  These  inferences  are  justi- 
fied provided  of  course  that  disease  of  the  semicircular  canals 
itself   has   been   excluded.      A   special   revolving  chair   and   a 


VERTIGO.  617 

highly  specialized  technique  has  been  devised  by  Barany, 
which,  in  trained  hands,  yields  most  interesting  and  detailed 
information. 

The  affections  of  the  ear  which  may  be  attended  by  vertigo 
are  most  varied.  The  disturbance  may  have  its  origin  in  the 
external,  the  middle,  or  the  internal  ear.  Commonly,  more  or 
less  decided  impairment  of  hearing  is  present.  Usually  this 
impairment  is  accompanied  by  a  diminution  of  bone  conduc- 
tion, and  with  especial  frequency  do  we  find  tinnitus  aurium. 
However,  neither  impairment  of  hearing  nor  tinnitus  is 
necessarily  present.  The  symptoms  in  the  majority  of  cases 
point  to  disease  of  the  labyrinth ;  disease  of  the  meatus  or 
middle  ear  should  always  be  excluded,  and  the  Barany  tests 
should  whenever  practicable  be  made.  In  the  form  of  vertigo 
described  by  Meniere,  the  cause  appears  to  have  been  hemor- 
rhage into  the  labyrinth.  Meniere's  disease  in  the  experience 
of  the  writer  is  quite  rare.  Frankl-Hochwart  was  able  to  find 
but  twenty-seven  cases  in  the  literature.  The  symptom  group 
is  somewhat  as  follows :  There  is  an  apoplectiform  onset ;  the 
patient  may  fall  to  the  ground ;  there  is  present  severe  nausea, 
vomiting,  deafness  and  tinnitus.  Curiously,  the  impairment 
of  hearing  is  usually  bilateral.  Gradually  the  nausea  and 
vomiting  subside,  and,  little  by  little,  the  vertigo  lessens,  and 
may  altogether  disappear.  More  or  less  marked  impairment  of 
hearing,  however,  as  a  rule,  remains.  The  diagnosis  of 
Meniere's  disease  is  to  be  based  upon  the  suddenness  of  the 
attack,  the  deafness,  the  tinnitus,  the  intense  character  of  the 
vertigo,  and  especially  upon  the  results  of  the  Barany  tests. 

Ocular  vertigo  is  very  rare.  It  is  at  times  associated  with 
double  vision;  at  others  with  an  erroneous  projection  of  the 
visual  field.  It  is  seldom  intense,  and  the  cause  is  usually 
revealed  by  the  ophthalmologic  examination. 

The  vertigo  associated  with  disturbances  of  the  stomach  is 
so  closely  associated  with  the  taking  of  food  and  with  the 
symptoms  of  indigestion,  that  the  diagnosis  is,  as  a  rule,  very 
readily  made.  This  is  also  true  of  the  vertigo  associated  with 
constipation. 

Disease  of  the  cardio-vascular  apparatus  is  not  infrequently 
accompanied  by  vertigo.  In  cases  of  heart  disease  it  must  of 
course    be    differentiated    from    transient    attacks    of    cardiac 


618  DISEASES    OF   THE    NERVOUS    SYSTEM. 

weakness.  It  is  also  important  to  bear  in  mind  that  vertigo 
may  be  an  accompaniment  of  sclerosis  of  the  cerebral  vessels, 
and  possibly  of  general  arteriosclerosis. 

The  determination  of  the  cause  of  vertigo  depends,  of 
course,  upon  the  detailed  study  of  each  individual  case.  It 
should  be  further  borne  in  mind  that  the  milder  forms  of  ver- 
tigo, especially  those  to  which  the  patient  applies  the  term 
dizziness  or  giddiness,  are  subjective,  and  are  relatively  unim- 
portant. Quite  commonly  they  are  part  of  the  symptom- 
group  of  neurasthenia,  and  rapidly  disappear  with  treatment. 
General  principles  must  also  guide  the  practitioner  in  the  treat- 
ment of  vertigo  when  the  latter  is  dependent  upon  visceral 
disease ;  this  is  also  the  case  when  no  special  cause  can  be  dis- 
covered. Among  other  things,  also,  the  possibility  of  a 
toxemia  should  be  considered. 

When  the  vertigo  is  labyrinthine  and  persistent,  purgatives, 
sweating,  counterirritation  back  of  the  ear,  absolute  rest  in 
bed,  the  iodids,  bromids,  and  perhaps  other  sedatives  may 
be  employed.  These  and  similar  measures  are  also  justifiable 
when  no  cause  for  the  vertigo  can  be  discovered.  It  may  be 
worth  while  to  add  that  Babinski  has  in  some  cases  practised 
lumbar  puncture  with  benefit.  In  very  desperate  and  severe 
cases,  the  attempt  appears  to  be  justifiable  to  secure  relief  by 
extirpation  of  the  semicircular  canals.  Lake  and  Milligan 
report  such  cases. 

EPILEPSY. 

Epilepsy  is  a  symptom-group  of  multiple  origin  character- 
ized by  irregularly  recurring  8,ttacks  in  which  loss  of  con- 
sciousness is  the  dominant  feature.  The  attacks  may  or  may 
not  be  attended  by  convulsions. 

Petit  mal,  or  the  mild  form,  is  characterized  merely  by  a 
momentary  loss  of  consciousness,  while  grand  mal,  or  the  major 
form,  presents,  in  addition  to  the  loss  of  consciousness,  also 
convulsions.  The  attacks  are  frequently  ushered  in  by  pre- 
monitory symptoms,  usually  sensory,  though  sometimes  motor. 
They  are  spoken  of  as  the  aura,  or  signal,  symptom.  It  is 
frequently  described  as  a  numbness  or  tingling,  or  other 
strange  sensation  arising  in  an  extremity,  in  the  epigastrium 
or  elsewhere,  and  spreading  upward  Xo  th^  head,  wh^ii  cgn- 


EPILEPSY.  619 

sciousness  is  lost  and  the  attack  supervenes.  The  aura  may 
also  arise  in  one  of  the  special  senses;  thus  the  attack  may 
begin  by  ringing  in  the  ears,  bright  flashes  of  light  and  colors, 
or  by  strange  tastes  and  smells.  Not  infrequently  the  attack 
is  ushered  in  by  a  cry.  The  patient  loses  consciousness,  falls 
to  the  g'round,  passes  into  a  tonic  spasm  involving  in  the  gen- 
eralized form  the  muscles  of  the  limbs,  trunk  and  head.  This 
tonic  spasm  is  of  very  brief  duration,  and  is  immediately  suc- 
ceeded by  active  clonic  movements,  usually  quite  rapid, 
though  not  very  large  in  extent.  The  duration  of  the  attack 
usually  covers  a  few  minutes  only.  Gradually  the  violence  of 
the  convulsion  moderates,  the  patient  becomes  quiet,  and  con- 
sciousness returns.  The  patient  seems  somewhat  heavy  and 
stupid,  may  complain  of  headache,  may  vomit,  and  usually 
falls  asleep.  Not  infrequently  the  tongue  is  bitten  during  the 
attack,  while  the  urine,  and  at  times,  though  much  less  fre- 
quently, the  bowels  may  be  voided. 

Sometimes  instead  of  having  a  convulsion,,  the  patient  may 
become  suddenly  and  actively  confused  or  delirious.  Such 
states  may  last  several  hours,  or  even  a  number  of  days,  and 
during  their  continuance  he  may  be  destructive  and  very 
violent.  Fatal  assaults  may  even  be  committed.  At  other 
times  comparatively  mild  states  of  automatism  alone  are 
present. 

Epilepsy,  or  the  epilepsies,  as  we  should  properly  speak  of 
them,  are  of  very  varied  value  and  character.  Thus,  in  a 
notable  percentage  of  cases  we  meet  with  neuropathic  family 
histories,  and  in  a  smaller  number  a  history  of  a  collateral  or  a 
direct  heredity.  In  others,  again,  there  is  a  history  of  alcohol- 
ism or  of  syphilis  in  the  ancestry,  and  the  inference  is  unavoid- 
able that  in  a  large  number  of  epileptics,  there  has  been  a 
primary,  a  basic  impairment  of  the  germ  plasm.  This  impair- 
ment may  be  general  in  character,  the  result  of  various  intoxi- 
cations and  infections  in  the  ancestry ;  or  the  impairment  may 
be  special  in  character,  and  may  result  in  the  special  trans- 
mission of  epilepsy. 

Concerning  the  evidence  of  the  direct  production  of  epi- 
lepsy in  the  individual  himself  b}^  intoxications  and  infections, 
the  evidence  is  overwhelming.  This  is  notably  true  of  alcohol. 
Again,  the  convulsions  which  at  times  accompany  or  usher  in 


620  DISEASES    OF   THE    NERVOUS    SYSTEM. 

the  acute  infectious  diseases  of  childhood  are  to  be  regarded 
merely  as  epiphenomena  of  the  infectious  process,  and  are  to 
be  explained  by  a  direct  toxic  action  on  the  brain  cortex.  Such 
convulsive  seizures  generally  disappear  with  the  infection,  but 
unfortunately  they  now  and  then  persist  as  established  epilep- 
sies. Sometimes  there  is  an  interval  of  months  or  years  dur- 
ing which  the  convulsions  are  absent,  and  after  which  they 
reappear.  It  is  probable  that  in  such  cases  an  encephalitis, 
perhaps  limited  in  area,  has  occurred  during  the  attack  of  the 
infectious  disease,  and  that  this  has  been  followed  by  sclerotic 
changes,  the  latter  being  then  sufficient  to  act  as  the  starting 
point  for  epileptic  attacks. 

Another  factor  in  the  production  of  epilepsy  is  trauma. 
Epilepsy  following  injury  to  the  brain  is  generally  Jacksonian 
in  type,  but  it  is  not  improbable  that  changes  may  supervene 
in  the  traumas  of  childhood  which  may  later  give  rise  to  the 
picture  of  a  generalized  epilepsy. 

When  we  study  the  etiology  of  epilepsy  we  are  impressed 
with  the  fact  that  epilepsy  is  not  a  definite  clinical  entity;  that 
under  this  name  are  included  many  symptom-groups,  which 
differ  widely  as  to  their  origin.  The  pathologic  findings  are  of 
significance,  and  in  keeping  with  this  view.  Many  years  ago, 
one  of  us  placed  on  record  anatomic  studies  of  twelve  epileptic 
brains,  all  of  which  revealed  more  or  less  marked  anomalies  of 
the  convolutions  and  fissures.  These  findings  were  to  be 
interpreted  as  phenomena  of  arrest  and  deviation.  A  similar 
interpretation  is  to  be  placed  on  the  sclerosis  of  the  cornu  am- 
monis,  so  much  insisted  on  by  the  earlier  writers.  Develop- 
mental arrest  and  deviation  have  the  same  significance  as  the 
asymmetries  and  malformations  of  the  skull.  Microscopic 
studies  of  the  brain  have  sometimes  revealed  atrophic  changes 
in  the  cortical  cells,  and  sometimes  a  proliferation  of  the  glia. 
Macroscopic  studies  have  shown  thickening  of  the  skull  and 
membranes,  and  the  adhesion  of  the  latter  to  the  skull  or  brain. 
The  factor  of  most  significance,  however,  is  that  none  of  these 
findings  are  constant. 

Some  epileptics  present  symptoms  suggestive  of  involve- 
ment of  the  internal  secretions,  but  anomalies  in  the  develop- 
ment of  the  glands  of  internal  secretions  may  well  accompany 
general  arrest  and  deviation.     No  special  internal  symptom- 


EPILEPSY.  621 

group  is  presented.  In  quite  a  number  of  epileptics,  Dercum 
demonstrated  a  number  of  years  ago,  by  Rontgen-ray  exami- 
nation, enlargement  and  distortion  of  the  pituitary  fossa  due 
apparently  to  disease  of  the  hypophysis. 

TREATMENT. 

The  first  consideration  of  treatment  is  that  the  patient  lead 
as  physiologic  a  life  as  possible.  There  should  be  little  or  no 
mental  or  physical  strain.  The  patient  should  live  close  to 
nature  on  farm  or  in  camp.  This  is  the  aim  and  object  in  the 
various  epileptic  colonies.  Under  such  circumstances  many 
patients  are  improved  in  general  health,  and  the  frequency  of 
attacks  lessened.  Undoubtedly,  benefit  arises  from  the  in- 
creased oxidation  of  waste  and  toxic  products,  brought  about 
by  the  life  in  the  open,  and  by  the  increased  physiologic 
efhciency. 

The  diet  should  be  so  modified  that  in  a  patient  already 
toxic  as  little  strain  as  possible  be  placed  on  the  liver,  thyroid, 
kidney  and  other  defensive  glands.  Very  little  meat,  and 
especially  red  meats,  should  be  eaten.  Carbohydrates  should 
be  diminished.  Large  amounts  hamper  the  oxidation  of  the 
tissues,  which,  in  a  patient  suffering  from  autointoxication, 
should  be  maintained  at  as  high  a  level  as  possible.  Succulent 
vegetables  and  milk  can  be  given  freely.  Stimulants  such  as 
alcohol,  tobacco,  tea  and  coffee  are  to  be  excluded.  The  vari- 
ous avenues  of  elimination  must  be  kept  freely  open.  If  con- 
stipation is  troublesome,  salines,  laxative  waters  or  cascara 
sagrada  may  be  given.  Thorough  irrigation  of  the  large  intes- 
tine once  or  twice  weekly  with  plain  water  benefits  many 
cases. 

Water  should  be  taken  freely  between  meals,  to  promote 
the  action  of  the  kidneys.  Daily  sponge  bathing  or  a  luke- 
warm tub  bath  will  stimulate  the  action  of  the  skin.  Cold  or 
hot  baths  are  not  indicated. 

No  matter  how  carefully  the  life  of  the  patient  is  regulated, 
we  must  in  many  cases  resort  to  medicines.  Mild  cases,  with 
attacks  at  infrequent  intervals,  may  do  well  on  proper  hvgiene 
and  diet,  but  those  having  frequent  attacks  do  better  under 
medication.    The  usefulness  of  the  various  bromid  salts  gives 


622  DISEASES    OF   THE    NERVOUS    SYSTEM. 

them  the  first  claim  to  our  attention.  In  tlie  administration  of 
the  bromid  we  should  reniember  that  the  sodium  or  ammon- 
ium salts  are  less  depressing  than  the  potassium  salt.  Stron- 
tium bromid  in  the  experience  of  the  writers  offers  no  special 
advantage.  It  is  important,  furthermore,  to  bear  in  mind  the 
procedure  introduced  by  Richet  and  Toulouse,  that  is,  to  reduce 
the  amovmt  of  the  sodium  chlorid  in  the  food  of  the  patient 
to  a  minimum.  The  sodium  bromid  appears  in  a  measure  to 
substitute  the  sodium  chlorid  in  the  tissues.  It  is  to  a  great 
extent  retained  in  the  economy  and  is  efficient  in  a  much 
smaller  dose. 

Chloral  hydrate  may  be  combined  with  bromids  for  a  short 
time  to  control  severe  groups  of  seizures,  but  it  should  never  be 
continued  long.  Occasionally  small  doses  of  belladonna  or  of 
hyoscyamus  increase  the  efficiency  of  the  bromids,  but  they 
also  are  not  suited  for  continued  administration.  Fowler's 
solution  in  small  doses  may  be  given  with  the  bromids  to 
lessen  the  tendency  to  acne.  Antipyrin  also  given  with  bro- 
mids may  re-enforce  the  action  of  the  latter.  Among  the 
more  recent  remedies  found  to  be  of  value  in  controlling  the 
seizures  are  luminal  and  luminal  sodium.  Given  in  1-  to  3- 
grain  (0.06  to  0.19  Gm.)  doses  three  times  daily  they  are  very 
efficacious,  and  are  unaccompanied  by  any  unfavorable  effects. 
The  remedy  may  apparently  be  continued  for  a  long  time. 

If  the  epilepsy  be  purely  nocturnal,  a  3-grain  (0.19  Gm.) 
dose  of  luminal  or  luminal  sodium,  or  sulphonal,  5  to  10  grains 
(0.32  to  0.65  Gm.),  proves  very  satisfactory  in  preventing  the 
seizures. 

At  times  the  administration  of  small  doses  of  thyroid  does 
good.  It  is  proba1)le  that  the  thyroid  extract  acts  by  stimulat- 
ing the  chain  of  glands  of  internal  secretion  generally,  and 
thus  increasing  metabolism.  Probably  the  oxidation  of  waste 
substances  is  favored  by  this  means. 

INFANTILE    CONVULSIONS. 

Infants  and  young  children  are  more  liable  to  convulsive 
seizures  than  older  children  or  adults.  This  is  possibly  due  to 
the  more  irritable  condition  of  the  nerve  centers,  and  a  com- 
paratively feeble  inhibition. 


INFANTILE    CONVULSIONS.  623 

Clinically  infantile  convulsions  separate  themselves  into 
those  which  occur  immediately  or  shortly  after  birth,  and  those 
which  occur  after  the  lapse  of  several  months,  or  within  the 
first  two  or  three  years.  The  convulsions  of  the  new-born  may 
be  due  to  traumata  of  the  brain  occurring  during  difficult  labor, 
e.g.,  from  prolonged  compression  of  the  head,  or  other  condi- 
tions involving  delay  and  instrumental  interference.  The  most 
common  lesion  is  meningeal  hemorrhage.  The  convulsions 
may  be  slight  and  brief,  or  they  may  be  severe  and  pro- 
longed. Further,  they  may  be  accompanied  by  distinct  localiz- 
ing signs. 

If  indications  are  at  all  clear^  such  cases  should  be  treated 
surgically,  the  skull  opened  and  the  clots  evacuated.  How 
much  can  be  accomplished  has  been  shown  by  Gushing.  How 
urgent  surgical  interference  is,  is  shown  by  the  disastrous  re- 
sults of  meningeal  hemorrhage.  Mental  arrest,  diplegia,  hemi- 
plegia, and  epilepsy  are  the  common  sequelae. 

Convulsions  such  as  are  due  to  organic  lesions  in  the  brain 
and  meninges  are  rare  in  the  first  few  months  of  life.  Subse- 
quently convulsions  may  make  their  appearance,  e.g.,  during 
the  period  of  dentition,  and  are  then  generally  due  to  some  gas- 
tro-intestinal  disturbance.  Quite  commonly  the  explanation 
is  to  be  sought  in  an  attack  of  indigestion,  the  result  of  over- 
feeding, or  of  the  giving  of  unsuitable  food.  The  convulsion 
may  come  on  while  there  is  still  undigested  food  in  the  stom- 
ach, and  in  such  case  the  attack  may  be  relieved  bv  vomiting. 
More  frequently,  however,  the  convulsion  does  not  come  on 
until  several  hours  have  elapsed ;  intestinal  indigestion  may 
then  be  the  direct  cause  of  the  convulsion.  The  formation  of 
irritant  and  toxic  materials  appears  also  to  plav  a  role. 
Chronic  gastro-intestinal  disturbances,  e.g.,  gastro-enteritis  and 
intestinal  infection,  it  should  be  added,  are  less  frequently 
accompanied  by  convulsions  than  are  acute  disturbances. 

Among  other  causes  of  convulsions  in  infancy  and  childhood 
are  the  infectious  diseases.  Here  the  special  cause  at  work  is 
apparently  the  action  on  the  cortex  by  the  bacteria  and  their 
toxins.  Convulsions,  too,  occur  more  frequently  in  children 
of  neuropathic  make-up  and  heredity,  and  it  is  not  impossible 
in  such  cases  various  causes  of  peripheral  irritation  may  plav  a 
role,  though  the  evidence  is  usually  not  conclusive.     The  pos- 


624  DISEASES    OF   THE    NERVOUS    SYSTEM. 

sibility  of  intestinal  parasites,  and,  lastly,  of  uremia  should  be 
borne  in  mind. 

Infantile  convulsions  in  a  general  way  resemble  epileptic 
seizures.  Frequently  also  there  are  prodromal  signs.  The 
child  is  apt  to  be  restless.  Occasionally  the  local  twitching  of 
a  muscle  or  of  an  extremity  may  be  noted ;  often,  too,  there  is 
gritting  of  the  teeth.  The  pulse  rate  is  usually  decidedly  in- 
creased, and  there  may  also  be  a  rise  of  temperature.  The 
latter  of  course  suggests  a  gastro-intestinal  or  other  infection. 

The  convulsion  generally  comes  on  suddenly.  Distinct 
shocks  make  their  appearance  in  the  extremities,  and  the  con- 
vulsion follows.  The  eyes  may  turn  upward,  may  deviate  to 
one  side,  or  may  rapidly  twitch  to  and  fro;  or  a  transient  or 
intermittent  strabismus  may  be  noted.  The  pupils  vary, 
though  they  are  usually  contracted,  the  more  so  the  more 
violent  the  seizure.  Usually,  as  in  epilepsy,  the  attack  begins 
as  a  tonic  spasm,  quickly  followed  by  clonic  movements;  but 
it  may  be  clonic  throughout.  The  urine  and  bowels  are  usually 
not  evacuated,  but  this  may  occur.  The  child  is,  as  a  rule, 
quite  unconscious,  and,  if  the  convulsion  be  prolonged,  it 
becomes  cyanotic  owing  to  interference  with  respiration.  It 
may  cry  out  as  the  attack  comes  on  or  subsides.  Usually 
there  is  no  cry  during  the  attack.  The  convulsive  seizures  may 
subside,  may  be  repeated,  or  may  terminate  fatally.  Increase 
of  pulse-rate  is  present  during  the  intervals.  Fever  also  may 
be  present. 

Death  may  ensue  during  a  convulsion,  either  from  exhaus- 
tion or  from  the  toxins  of  the  disease  producing  the  convul- 
sion. Not  infrequently  it  is  preceded  by  a  rapid  and  high  rise 
in  temperature. 

TREATMENT. 

The  treatment  of  infantile  convulsions  must  be  directed  if 
possible  alike  to  the  cause  and  to  the  convulsion  itself.  If  the 
attack  owes  its  origin  to  a  digestive  disturbance,  we  should, 
according  to  circumstances,  encourage  vomiting,  practise  free 
lavage  of  the  bowel,  using,  if  there  be  fever,  cold  or  iced  water. 
Free  evacuations  should,  if  possible,  be  secured  by  small  doses 
of  calomel,  followed  by  castor  oil.  Other  things  equal,  the 
child  should  be  immersed  in  a  warm  bath,  and  cold  applied  to 


PUERPERAL   CONVULSIONS.  625 

the  head.  Bromid,  bromid  and  chloral,  or  bromid  and  anti- 
pyrin  may  be  given  by  the  mouth,  or  perhaps  better  by  the 
bowel.  Caution  and  judgment  must  of  course  be  exercised, 
both  as  regards  the  size  of  the  doses  and  their  repetition.  If 
the  convulsions  are  very  severe  and  persistent,  it  is  perfectly 
justifiable  to  make  a  cautious  trial  of  a  few  drops  of  chloro- 
form inhalation.  Finally,  we  believe  it  to  be  perfectly  proper 
also,  in  such  cases,  to  resort  to  spinal  puncture. 

In  former  years  difficult  dentition  was  popularly  believed 
to  be  a  cause  of  convulsions.  It  cannot  do  any  harm,  of  course, 
in  a  given  case  to  freely  lance  the  gums.  In  cases  in  which  the 
convulsions  are  part  of  the  invasion  of  one  of  the  exanthemata, 
the  management  of  the  case  is  of  course  that  of  the  infection. 
The  convulsion  itself,  however,  may  demand  immediate 
attention. 

PUERPERAL    CONVULSIONS. 

Convulsive  seizures  may  make  their  appearance  during 
pregnancy,  usually  during  the  latter  part  of  gestation,  during 
childbirth,  or  during  the  puerperal  period.  They  occur  most 
frequently  in  young  primiparse.  They  may  be  renal  in  origin, 
but  it  frequently  happens  that  the  urine  is  entirely  negative  to 
examination,  both  as  to  albumin  and  casts ;  at  most  only  a 
trace  of  albumin  may  be  found.  On  the  other  hand,  women 
with  well  recognized  Bright's  disease  may  successfully  pass 
through  both  pregnancy  and  childbirth.  An  adequate  explana- 
tion of  puerperal  convulsions  has  not  yet  presented  itself.  Of 
course,  a  toxic  cause  seems  necessarily  to  be  present.  It  may 
be  that  a  special  disturbance  of  metabolism  is  present,  together 
perhaps  with  renal  insufficiency.  There  are  good  reasons  for 
believing  that  neither  the  fetus  nor  the  placenta  is  the  cause 
of  the  eclampsia ;  a  convulsion  may  occur  after  the  uterus  is 
empty,  the  fetus  and  placenta  having  been  expelled ;  or  it  may 
"even  occur  with  a  hydatiform  mole. 

Prodromal  symptoms,  if  present,  consist  of  headache,  visual 
disturbances,  epigastric  distress,  restlessness  and  general  dis- 
comfort. The  attacks  greatly  resemble  epilepsy.  Further  they 
may  be  very  violent  and  prolonged,  as  in  status  epilepticus. 

40 


626  DISEASES    OF   THE    NERVOUS    SYSTEM. 

TREATMENT. 

If  patient  is  in  labor,  it  seems  best  to  hasten  the  latter  as 
much  as  possible.  On  the  other  hand,  if  labor  has  not  begun, 
it  is  the  consensus  of  opinion  not  to  induce  labor,  nor  to  empty 
the  uterus  by  surgical  procedure,  such  as  section,  but  to  en- 
deavor to  control  the  seizures.  If  the  latter  are  severe,  this 
may  be  accomplished  by  the  cautious  use  of  an  anesthetic,  such 
as  ether  or  chloroform.  Bromids,  chloral,  morphin,  may  also 
be  given  in  full  doses,  either  separately  or  in  combination,  as 
may  seem  wise.  In  order  to  combat  the  toxicity  which  is 
undoubtedly  present,  it  may  be  well  to  practise  venesection, 
and  to  follow  the  latter  by  a  simple  saline  solution  intraven- 
ously. Hypodermoclysis  may  be  practised  instead,  but  its 
action  is  less  direct  and  slower.  It  is  in  keeping  further  with 
modern  procedures  to  add  sodium  bicarbonate  to  either  the 
intravenous  or  the  hypodermoclysis.  Alkalies  can  also  be 
given  by  the  bowel. 

Diaphoresis  should  be  encouraged.  The  hot  pack  may 
prove  very  serviceable.  Salines  and  liquids  should  be  freely 
administered  by  the  mouth. 

CHOREA. 

The  symptom-group  chorea  presents  itself  in  various  forms ; 
e.g.,  as  the  chorea  of  childhood,  chorea  minor,  Sydenham's 
chorea  or  St.  Vitus'  dance,  as  it  is  variously  termed;  also 
Huntingdon's  chorea  and  so-called  electric  chorea. 

Sydenham's  chorea  is  an  affection  of  childhood  character- 
ized by  irregular,  involuntary,  incoordinate  movements.  It 
usually  appears  between  the  seventh  and  the  thirteenth  years, 
and  is  more  common  in  girls  than  in  boys  in  the  proportion  of 
3  to  1.  Occurring  after  the  fifteenth  year,  it  is  generally  found 
in  the  female  sex.  Again,  it  may  occur  in  youth  or  in  adult 
life,  though  it  is  very  rare  in  the  latter  period.  Finally,  it  is 
among  the  rare  sequelae  of  scarlet  fever,  measles  or  typhoid, 
and  it  is  noteworth}^  that  the  prognosis  in  such  cases  is  not  so 
favorable  as  in  ordinary  chorea.  Occasionally  chorea  is  noted 
during  pregnancy.  Here  it  usually  occurs  in  primiparae,  and 
during  the  early  months.  It  is  also  rarely  met  with  in  old  age, 
but  we   may   question   the   correctness   of  classifying  senile 


CHOREA.  627 

chorea  with  the  chorea  of  Sydenham.  In  the  chorea  of  child- 
hood there  is  frequently  a  prodromal  period  of  pains  in  the 
joints.  A  history  of  swelling-  in  the  joints  cannot  be  elicited; 
nevertheless  the  fact  points  to  an  infectious  process.  Not 
infrequently,  also,  an  endocarditis  is  noted.  The  consensus  of 
opinion  favors  the  view  of  a  microbic  infection,  though  a 
specific  g-erm  has  not  been  isolated.  Possibly  infections  finding 
their  way  through  the  nose,  throat,  tonsils  or  middle  ears  play 
here  a  role. 

The  patient  may  in  the  beginning  be  dull,  peevish,  irritable, 
perhaps  a  trifle  awkward  and  restless.  Soon  irregular  mus- 
cular movements  begin,  generally  in  one  hand,  extending  to 
the  arm  and  face,  or  may  spread  over  the  entire  half  of  the 
body.  Occasionally  it  is  limited  to  one-half  of  the  body,  and 
is  then  spoken  of  as  hemichorea.  In  the  larger  number  of 
cases,  however,  the  opposite  side  also  becomes  involved.  The 
movements  do  not  consist  of  sudden  twitchings  or  spasmodic 
movements,  but  are  slower,  and  to  some  extent  simulate  vol- 
untary movements.  The  movements  are  generally  most 
marked  in  the  extremities  and  in  the  face,  but  they  may  involve 
the  eye  muscles,  the  muscles  of  speech,  and  even  of  deglutition. 

Quite  commonly  the  afifected  muscles  are  somewhat  weak. 
The  electric  reactions,  however,  of  both  nerves  and  muscles 
remain  normal.  The  reflexes  are  usually  unchanged,  and 
there  is  no  involvement  of  the  sphincters.  Choreic  movements 
cease  during  sleep.  They  may,  however,  be  so  pronounced  as 
to  seriously  interfere  with  sleep.  Again  they  may  be  so  violent 
and  so  widely  diffused  as  to  make  it  impossible  for  the  patient 
either  to  stand  or  to  walk.  Mentally  the  patient  is  irritable 
and  emotional,  or  dull  and  apathetic.  In  very  severe  cases  he 
may  become  confused  and  even  delirious. 

The  duration  of  the  chorea  of  childhood  is  generally  from 
six  to  twelve  weeks.  The  prognosis  is  on  the  whole  very 
favorable ;  a  small  percentage  (only  3  or  4)  die  of  exhaustion, 
or  of  cardiac  or  other  complication.  The  more  prolonged  cases 
are  apt  to  be  among  older  patients,  and  are  more  often  com- 
plicated by  endocarditis.  It  is  important  to  bear  in  mind  that 
one  attack  does  not  confer  ^mmunit}^  but  the  affection  is  prone 
to  recur.  At  least  one-fourth  of  the  cases  suffer  from  two, 
three  and  often  more  attacks. 


628  DISEASES   OF   THE   NERVOUS    SYSTEM. 

TREATMENT. 

Rest  is  the  first  principle  of  treatment.  The  child  should 
be  taken  from  school,  and,  if  the  disease  becomes  at  all  severe, 
rest  in  bed  should  be  instituted.  In  the  milder  cases  the  patient 
may  be  permitted  to  remain  up  and  about,  but  even  here  the 
hours  spent  in  bed  should  be  increased.  The  diet  should  be 
liberal  and  nutritious.  Milk  should  be  given  freely,  both  with 
and  between  meals. 

Arsenic  is  regarded  as  the  most  reliable  medicinal  agent. 
It  should  be  given  in  very  small  doses  at  first,  preferably  1 
drop  (0.06  mil)  of  Fowler's  solution  three  times  daily.  This 
may  be  gradually  increased,  by  1  drop  (0.06  mil)  daily  until 
3  or  possibly  4  drops  (0.18  to  0.24  mil)  are  given  three  times 
daily.  It  should  then  be  discontinued  for  a  few  days,  or  the 
dose  diminished  drop  by  drop  until  the  original  dose  is  reached, 
and  then  another  course  given.  The  physician  should,  of 
course,  be  alert,  and  discontinue  the  medicine  altogether  if 
puffiness  about  the  eyes,  or  g-astric  or  intestinal  disturbance 
be  noted.  Arsenic  is,  of  course,  not  necessary  to  the  success- 
ful treatment  of  chorea ;  and  unless  the  ph3^sician  has  con- 
fidence in  the  mother,  or  is  reasonably  sure  that  the  patient 
will  be  brought  to  see  him  at  reasonably  frequent  inter- 
vals, he  should  not  prescribe  the  remedy  at  all.  Every  now 
and  then  serious  chronic  poisoning  results  from  small  doses 
too  long  continued,  and  neuritis,  wasting,  and  palsy  may  be 
the  result.  Iron  is  a  much  safer  tonic.  Occasionally,  the 
salicylates  are  indicated,  and  prove  serviceable.  In  very  severe 
cases,  in  which  the  movements  are  violent  and  continuous, 
small  doses  of  trional,  veronal,  or  luminal  may  be  given.  The 
bromids  also  may  be  tried.     Chloral  is  rarely  indicated. 

Children  who  have  suffered  from  chorea  should  receive 
close  personal  attention ;  the  throat,  tonsils,  nose,  gastro-intes- 
tinal  tract  and  other  possible  avenues  of  infection  should  be 
carefully  studied. 

HUNTINGDON'S    CHOREA. 

Huntingdon's  chorea  is  a  hereditary  form  of  chorea,  which 
occurs  most  frequently  between  the  ages  of  35  and  40  years. 
It  rarely  begins  before  30  or  after  45. 


HUNTINGDON'S    CHOREA.  629 

The  disease  is  distinctly  hereditary;  it  is  transmitted 
directly  from  one  generation  to  the  next.  Huntingdon  in  his 
original  paper  stated  that  his  father  and  grandfather,  who  had 
practised  medicine  in  the  eastern  end  of  Long  Island  for  years, 
had  known  certain  families  in  which  this  disease  had  existed 
for  generations.  In  these  families  there  were  usuallyj  also, 
members  who  were  unaffected;  the  descendants  of  the  latter 
commonly  escaped.     Both  sexes  are  equally  liable. 

The  disease  comes  on  gradually.  It  generally  begins  in  the 
face  and  upper  extremities;  the  movements  at  first  are  slight. 
Later  they  become  more  general  and  more  pronounced.  Not 
only  the  limbs,  but  the  muscles  of  the  trunk  and  neck^  and 
even  of  the  throat,  also  become  involved.  The  movements  are 
involuntary,  incoordinate,  and  almost  uninterrupted.  The 
involvement  of  the  face,  neck  and  throat  muscles  leads  to 
difficulty  in  speech,  and  at  times  of  swallowing.  The  patient 
makes  grimaces,  gesticulates,  walks,  it  may  be,  with  legs  wide 
apart,  tottering  or  tripping,  now  very  slowly,  now  faster,  or  he 
may  stop  abruptly  altogether.  In  his  motions,  the  patient  may 
suggest  the  behavior  of  a  clown. 

The  movements  are  wider  in  range  and  more  extensive  than 
in  ordinary  or  Sydenham's  chorea.  Attempt  to  control  them 
or  emotional  excitement  makes  them  worse.  The  strength  ot 
the  muscles  does  not  seem  lessened.  Sensation  is  normal. 
The  reflexes  are  as  a  rule  increased.  Mental  symptoms  are 
commonly  added  to  the  picture.  The  patient  is  depressed ; 
sometimes  he  entertains  persecutory  ideas.  Later  mental  fail- 
ure becomes  evident.  The  disease  is  essentially  degenerative. 
It  is  very  slowly  progressive  and  incurable.  As  the  vears  pass 
by,  the  patients  gradually  lose  strength  and  are  finally  con- 
fined to  bed.  It  is  an  affection  of  a  very  slow  course,  a  dura- 
tion of  ten  to  thirty  years  not  being  uncommon. 

We  possess  no  definite  knowledge  of  its  pathology.  Vari- 
ous anatomic  changes  have  been  found  in  the  nervous  svstem. 
but  the  connection  of  these  with  the  s}'mptoms  is  not  clear. 
Among  these  changes  are  disseminated  foci  of  sclerosis,  dift'use 
meningoencephalitis,  atrophic  changes  in  the  cortex,  prolifera- 
tion of  neuroglia,  infiltration  of  the  cortex,  with  glia  cells, 
atrophic  changes  in  the  central  convolutions,  or  it  may  be  in 
other  portions  of  the  brain. 


630  DISEASES    OF   THE    NERVOUS    SYSTEM. 

TREATMENT. 

The  treatment  is  purely  symptomatic.  Practically  we  are 
restricted  to  simple  hygienic  care.  Rest  methods  and  othet 
physiologic  procedures,  so  useful  in  functional  nervous  dis- 
eases, fail  here  altogether.  Gentle  gymnastic  exercises  have 
been  recommended,  and  are  perhaps  useful  in  encouraging  and 
occupying-  the  patient.  At  times  the  movements  become  very 
pronounced,  and  in  such  case  warm  baths  and  sedatives  should 
be  resorted  to.  Occasionally,  too,  the  mental  symptoms 
become  so  severe  as  to  necessitate  the  commitment  of  the 
patient  to  an  institution. 

ELECTRIC    CHOREA. 

Under  this  name  are  described  various  affections  of  un- 
known origin,  and  a  legitimate  doubt  arises  as  to  whether  the 
term  chorea  is  not  improperly  applied  to  them.  It  is  not  im- 
probable that  many  cases  of  so-called  electric  chorea  really 
belong  to  the  category  of  hysteria.  The  term  has  been  applied 
to  cases  in  which  the  movements  occur  with  great  suddenness. 
Henoch  separated  from  the  ordinary  form  of  chorea  a  disease 
picture,  which  he  called  electric  chorea^  and  in  which  the  mus- 
cular twitchings  follow  one  another  with  lightning  rapidity, 
differing  in  this  respect  from  Sydenham's  chorea.  The  twitch- 
ings affect  generally  the  muscles  of  the  shoulder  and  neck.  A 
similar  form  has  been  described  by  Hirsch.  It  is  probable  that 
we  have  to  do  here  with  a  hysterical  myoclonia.  In  the  form 
of  electric  chorea  described  by  Bergeron,  we  have  an  affection 
in  which  sudden  spasms  make  their  appearance  in  children 
from  7  to  14  years  of  age,  children  usually  of  delicate  and 
anemic  appearance.  The  spasms  affect  the  muscles  of  the  back 
of  the  neck,  shoulders  and  arms,  and  shake  the  entire  body. 
Occasionally,  however,  one  extremity  only  is  affected.  At- 
tempts at  control  usually  aggravate  the  spasms.  The  affection 
likewise  strongly  suggests  hysteria.  The  prognosis  is  uni- 
formly favorable,  the  conditions  yielding  to  simple  physiologic 
methods  and  tonics. 

Dubini  describes  an  affection  occurring  in  northern  Italy, 
which  begins  with  pain  in  the  neck  and  back ;  soon  lightning- 
like    contractions    make    their    appearance    in    one-half    of    the 


TIC.  631 

body,  namely,  in  the  face,  arm  and  leg.  Subsequently  the 
opposite  side  of  the  body  becomes  involved.  Occasionally 
epileptiform  attacks  and  paralytic  phenomena  are  added.  Pain 
and  fever  are  also  present.  Later,  widely  diffused  palsies,  with 
wasting  of  muscles  and  change  in  the  electric  reactions,  fol- 
low. The  disease  generally  terminates  in  death ;  recovery  is 
rare.  Heart  failure  and  coma  terminate  the  picture.  It  is 
probably  an  infectious  disease. 

TIC. 

In  the  consideration  of  psychasthenia,  in  the  previous  pages, 
defects  of  inhibition  were  pointed  out  which  express  them- 
selves in  various  movements.  These  movements  frequently 
become  pronounced,  and  are  spoken  of  as  tic,  or  tic  convulsif. 
Quite  commonly  they  suggest  some  voluntary  or  automatic 
gestures. 

The  milder  form  of  tic  occurs  most  frequently  about  the 
face.  Very  frequently  it  consists  of  winking,  or  of  winking 
associated  with  other  movements.  At  other  times,  the  mouth 
and  lips  are  involved,  and  grimaces,  sniffling,  sudden  protrusion 
of  the  tongue,  and  other  bizarre  movements  result.  Some- 
times it  is  the  neck  and  shoulder;  the  patient  may  suddenly 
and  repeatedly  bow,  shrug  his  shoulders,  nod,  turn  or  throw 
back  his  head,  his  action  resembling  some  voluntar}-  move- 
ment. The  arms  may  be  involved,  the  hand  being  carried  to 
the  head,  the  face  or  the  beard.  Similarly,  the  lower  extremi- 
ties may  be  aft'ected,  though  to  a  less  extent.  The  patient  may 
suddenly  rise  from  his  chair,  take  a  step  or  two,  turn  about 
or  perform  some  other  curious  movement.  At  the  moment  of 
action  the  casual  observer  receives  an  impression  as  though 
the  movement  were  made  by  design.  At  the  same  time  the 
patient  often  emits  sounds  or  exclamations ;  sometimes  phrases 
or  parts  of  phrases,  the  latter  being  thrown  or  interlarded  in 
a  senseless  way,  into  the  speech  of  the  patient.  Not  infre- 
quently the  expressions  are  obscene  and  profane. 

The  phenomena  recur  at  irregular  intervals.  By  mental 
concentration,  the  movements  may  be  controlled  for  a  time ; 
but  frequently,  after  a  too  insistent  repression,  they  recur  with 
increased  force.    They  are  made  worse  also  by  excitement.    In 


632  DISEASES    OE   THE    NERVOUS    SYSTEM. 

addition  to  the  movements,  the  patient  may  also  suffer  from 
phobias  and  obsessions.  For  a  detailed  consideration  of  the 
latter,  the  reader  is  referred  to  the  section  on  psychasthenia. 

The  treatment  is  that  of  psychasthenia ;  rest,  full  feeding, 
and  hygienic  living.  Light  hydrotherapy  and  medical  gym- 
nastics are  useful.  Psychotherapy  also  is  of  value.  (See 
p.  605.) 

HABIT    SPASM. 

Closely  allied,  if  not  identical,  with  tic  convulsif  is  a  condi- 
tion described  by  S.  Weir  Mitchell  as  habit  chorea,  and  by 
Cowers  as  habit  spasm.  It  is  manifested  by  slight  spasmodic 
movements  of  small  groups  of  muscles,  which  result  in  winking 
or  twitching  of  the  mouth  or  other  transient  and  slight  grim- 
aces. The  movements  have  a  semi-voluntary  aspect.  The 
affection  usually  occurs  between  the  ages  of  6  and  14  years, 
and  is  apt  to  subside  as  the  child  grows  older.  In  rare  cases 
slight  movements  continue  during  youth,  and  even  through- 
out adult  life.  It  is  the  general  rule,  however,  that  cases  in 
which  mild  facial  twitchings  are  present  are  likely  to  get  well. 
Occasionally  the  movements  are  extensive,  involving  the  trunk 
and  limbs  and  then  constitute  true  tic;  in  such  a  case,  of 
course,  they  are  likely  to  persist. 

In  treatment  everything  should  be  done  to  raise  the  level 
of  the  general  health  of  the  patient.  An  extensive  considera- 
tion of  treatment  is  here  unnecessary.  Rest,  full  feeding, 
proper  hygiene,  and  the  giving  of  tonics  are  important. 

The  patient  must  be  examined  for  all  peripheral  sources  of 
irritation,  and  these  when  discovered  should  be  remedied.  The 
eyes  should  be  examined,  and  refracted  if  necessary.  Any 
disease  of  the  conjunctivae  should  be  treated.  Similar  atten- 
tion should  be  given  to  the  mouth,  nose  and  throat.  The 
teeth  should  be  put  in  good  condition ;  tonsils  and  adenoids 
removed  if  necessary ;  if  an  adherent  prepuce  is  present,  its 
removal  is  advised.  The  stools  should  be  examined  for  worms. 
Very  commonly,  however,  no  source  of  peripheral  irritation 
can  ht  found. 


LOCALIZED    MYOSPASMS.  633 

LOCALIZED    MYOSPASMS. 

Myospasms  affecting  a  muscle  or  group  of  muscles,  either 
tonic  or  clonic  may  affect  the  muscles  of  almost  any  portion  of 
the  body.  More  frequently,  however,  special  muscle  groups  or 
those  representing  special  nerve  distribution  are  involved. 

Facial  Spasm.  Clonic  facial  spasm,  or  painless  tic,  the 
form  most  commonly  met  with,  consists  of  an  irregularly 
recurring  contraction  of  the  muscles  supplied  by  the  facial 
nerve.  The  contraction  may  involve  all  the  facial  muscles,  or 
may  be  limited  to  certain  groups.  In  the  diffuse  form  the 
symptoms  are  limited  to  one-half  of  the  face,  though  it  occa- 
sionally happens  that  certain  movements,  such  as  winking,  are 
bilateral.  As  a  rule,  the  spasm  begins  in  one  group  of  muscles 
and  spreads  to  the  others ;  there  is,  however,  no  regularity  in 
the  order  of  sequence.  Thus  the  mouth  may  be  suddenly 
drawn  up,  the  alse  of  the  nose  twitch,  the  eyes  blink,  and  then 
the  whole  side  of  the  face  becomes  involved.  The  entire 
paroxysm  usuall}^  lasts  for  a  fraction  of  a  second  or  for  a  few 
seconds  only.  At  times,  though  infrequently,  it  lasts  for  a 
minute  or  even  longer.  In  rare  cases  the  spasm  consists  of  a 
single  muscular  contraction ;  more  frequently  it  is  made  vip  of 
a  number  of  clonic  movements  which  quickly  increase  in 
rapidity  until  a  maximum  is  reached,  when  they  again  become 
slower  and  gradually  die  away.  Sometimes  both  the  onset  and 
cessation  of  the  spasm  are  abrupt.  Following  the  spasm  there 
ensues  an  interval,  varying  in  different  cases,  in  which  the  face 
is  quiet,  or  almost  so.  Sometimes  this  interval  lasts  many 
minutes,  and  in  mild  cases  the  spasm  may  occur  onlv  occa- 
sionally in  the  course  of  the  day.  In  other  cases,  the  parox- 
ysms occur  with  such  frequency  as  almost  to  simulate  a  tonic 
spasm.  In  other  cases,  again,  in  which  a  decided  pause  is  pres- 
ent between  the  spasms,  minute  local  and  isolated  twitchings 
may  occur  during  the  interval.  As  a  rule,  the  contraction  of 
the  zygomatic  muscles  and  the  elevators  of  the  angles  of  the 
mouth  and  nose  predominate  over  the  contractions  of  the 
other  muscles. 

Next  in  frequency  the  spasm  affects  the  orbicularis  palpe- 
brarum, and  least  frequently  the  depressor  of  the  angle  of  the 
mouth.     The  occipito-frontalis,  the  muscles  of  the  ear,  the 


634  DISEASES  OF  THE  NERVOUS  SYSTEM. 

muscles  of  the  palate  and  the  platysma  are  very  rarely  in- 
volved. However,  no  muscle  of  the  facial  supply  is  exempt. 
Occasionally,  too,  the  spasm  is  not  limited  to  the  facial  supply 
alone,  but  radiates  into  other  nerve  territories.  In  such  cases  it 
may  involve  the  massaters  and  temporalis,  or  it  may  spread  to 
the  muscles  of  the  neck,  and  even  to  the  muscles  of  the  arms 
and  shoulders.  No  weakness  can  be  detected  in  the  affected 
muscles,  nor  is  there  any  chang'e  in  the  electrical  reactions. 
Further  facial  spasm  is  at  times  bilateral.  The  zygomatics  of 
both  sides  may  in  such  case  be  involved,  and  at  short  intervals 
a  grin  or  smile  passes  over  the  patient's  face.  At  other  times 
the  corrugators  are  affected,  the  patient  suddenly  frowning 
without  cause.  Again,  the  involvement  of  the  orbicularis  pal- 
pebrarum may  be  so  slight  as  to  cause  a  barely  perceptible 
twitching  of  the  eyelids,  or  it  may  be  so  pronounced  that  the 
contraction  may  last  for  several  seconds,  or  even  many  min- 
utes, or  it  may  be  so  severe  as  to  be  practically  continuous,  and 
thus  make  the  patient,  to  all  intents  and  purposes,  blind.  The 
eyes  may  be  so  firmly  closed  during  a  spasm  that  no  effort  of 
the  patient's  will  can  open  them.  Curiously  enough,  blepharo- 
spasm can,  at  times,  be  relieved  by  pressure  of  the  finger  on 
certain  points ;  for  instance,  over  the  supra-orbital  notch  or 
over  the  supra-orbital  nerves  upon  the  brow.  Now  and  then 
such  points  are  found  on  the  infra-orbital  branch  of  the  fifth 
nerve,  and  sometimes  upon  areas  that  bear  no  relation  what- 
ever to  nerve  distribution.  Thus  they  have  been  found  on  the 
back  of  the  neck,  on  the  shoulder,  in  the  axilla,  and  on  the 
arm  as  low  down  as  the  wrist.  Pressure-points  may  be  met 
with  not  only  in  blepharospasm,  but  also  in  generalized  facial 
spasm.  The  point  to  be  considered  in  these  curious  cases  is 
whether  or  not  hysteria  plays  a  role. 

TREATMENT. 

The  mouth,  teeth,  eyes  and  nose  should  be  carefully  ex- 
amined. The  fifth  nerve  should  be  thoroughly  explored 
throughout  its  various  divisions,  and  this  result  proving  nega- 
tive, the  entire  body  should  be  examined,  and,  especially  in 
children,  the  intestinal  tract  must  not  be  forgotten. 

Quite  commonly  nothing  is  found  to  which  the  affection 
can  be  attributed,  and  we  are  forced  to  treat  the  latter,  symp- 


LOCALIZED    MYOSPASMS.  635 

tomatically.  Among  the  measures  that  have  been  adopted  are 
counterirritation  by  blistering,  or  by  the  actual  cautery  over 
a  small  area  over  the  cervical  spine  or  back  of  the  ear.  Freez- 
ing of  the  face  with  a  volatile  spray  may  be  tried,  but  neither 
counterirritation  nor  freezing  gives  very  decided  results.  The 
results  of  the  constant  galvanic  electric  current  and  of  other 
electric  treatment  are  so  poor  as  to  hardly  make  them  worth 
the  trial. 

Surgical  treatment  is  of  more  or  less  benefit,  though  as  a 
rule  for  a  limited  time  only.  Stretching  of  the  facial  nerve  is 
very  efficient,  but  as  soon  as  the  ensuing  paralysis  disappears 
the  spasm  reasserts  itself.  During  the  interval,  however,  the 
patient  is  relieved  for  many  weeks,  and  even  months.  Section 
of  the  facial  nerve,  of  course,  yields  a  similar  result,  and  the 
relief  is  naturally  of  longer  duration,  but  when  union  of  the 
nerve  takes  place  the  spasm  returns. 

Deep  alcoholic  and  osmic  acid  injections  may  be  tried. 
These  often  give  decided  results,  which  are  usually  more  per- 
sistent than  those  obtained  by  stretching,  while  the  resulting 
weakness  of  the  nerve  is  not  so  serious  as  that  resulting  from 
section.  Various  drugs  have  been  employed  internally,  but 
without  decided  benefit.  In  very  severe  cases  of  blepharo- 
spasm, and,  indeed,  all  other  forms  of  facial  spasm,  there  is 
but  one  drug  which  has  a  marked  effect,  and  this  is  morphin. 
When  used  internally,  or,  better  still,  when  injected,  hypo- 
dermically  near  the  exit  of  the  nerve,  it  markedly  lessens  the 
spasm.  However,  morphin  is  rarely  a  drug  one  is  justified 
in  using  in  such  cases,  the  cure  being  worse  than  the  disease. 
Deep  alcohol  injections  are  much  to  be  preferred. 

The  general  hygiene  of  the  patient  should  receive  care,  as 
in  other  functional  nervous  diseases,  and  the  reader  is  referred 
to  the  methods  employed  in  the  treatment  of  neurasthenia  and 
hysteria.  We  should  bear  in  mind  that  along  with  facial 
spasm,  the  patient  often  presents  the  signs  of  more  or  less 
marked  deterioration  of  nervous  health. 

Tonic  Facial  Spasm.  In  a  given  number  of  cases  we  meet 
with  tonic  spasm,  or  contraction  of  the  face.  This  is  most  fre- 
quently met  with  as  an  after-result  of  Bell's  palsy ;  the  muscles 
having  been  parahzed  for  a  long  time,  secondary  contracture 
supervenes,  just  as  it  does  in  the  muscles  of  the  arms  and  legs 


636  DISEASES    OF   THE    NERVOUS    SYSTEM. 

in  hemiplegia.  Very  rarely  tonic  facial  spasm  is  said  to  fol- 
low exposure  to  cold,  and  also  to  be  an  accompaniment  of 
hysteria.  The  writers  have  never  observed  this.  The  treat- 
ment of  tonic  facial  spasm  or  contracture  is,  as  a  rule,  ineffect- 
ual, though  sometimes  vigorous  facial  massage,  with  stretch- 
ing of  the  contracted  muscles,  is  beneficial.  The  constant 
galvanic  current  also  may  be  employed. 

SPASMODIC    TORTICOLLIS. 

Spasmodic  torticollis,  also  termed  spinal  accessory  spasm, 
consists  of  a  spasm  of  certain  muscles  by  which  the  head  and 
neck  are  rotated  to  one  side,  or  frOm  side  to  side.  The  spasm 
involves  either  one  or  more  muscles,  especially  the  sterno- 
cleidomastoid and  the  trapezius,  but  also  the  splenius,  the 
scaleni,  and  the  deeper  rotators  of  the  head  and  neck.  Be- 
cause of  the  relatively  large  size  of  the  sternocleidomastoid 
and  trapezius,  the  movement  is  largely  influenced  by  their 
action.  However,  that  rotatory  spasm  may  occur  indepen- 
dently of  these  muscles  is  shown  by  cases  in  which  the  spinal 
accessory  ner\'e  has  been  resected,  the  movement  persisting 
in  spite  of  the  resulting  paralysis. 

Spasmodic  torticollis  is  quite  characteristic.  Every  few 
seconds  or  every  minute  the  head  is  forcibly  drawn  to  one 
side,  the  mastoid  region  depressed,  the  chin  elevated  and 
turned  toward  the  opposite  shoulder.  There  are  many  modi- 
fications of  this  movement,  depending  on  the  action  of  the 
muscles  involved.  It  should  be  remembered  too  that  the 
affection  is  one  of  the  function  of  rotation,  and  not  of  individ- 
ual muscles.  The  action  of  the  sternomastoid,  as  a  rule,  is 
easily  seen ;  the  muscle  stands  out  prominently  during  the 
spasm,  and  becomes  very  hard  to  the  touch ;  at  times,  it 
undergoes  marked  hypertrophy.  Similar  though  less  marked 
changes  may  be  observed  in  the  trapezius.  The  spasm  varies 
in  character  in  different  cases.  Sometimes  it  consists  of  a 
series  of  short,  jerky  movements.  At  other  times  it  is  a  long, 
continuous  movement,  in  which  the  head  and  chin  are 
moved  through  an  area  of  relatively  wide  extent.  In  pro- 
nounced cases  the  torsion  of  the  head  and  neck  is  so  marked 
as  to  attain  the  possible  maximum.     In  exceptional  cases  the 


SPASMODIC  TORTICOLLIS.  637 

spasm  lasts  for  many  minutes  at  a  time,  so  that  the  head  is 
held  more  or  less  fixed  in  one  position.  Very  curiously,  in  a 
majority  of  cases,  the  muscles  of  the  right  side  are  the  ones 
involved. 

Quite  commonly  the  intervals  between  the  attacks  of 
spasm  are  relatively  long-,  and  usually  constitute  periods  of 
complete  or  almost  complete  rest;  at  other  times  they  are  so 
short  that  the  contractions  appear  to  be  almost  continuous. 
The  spasm  usually  ceases  during-  sleep;  exceptionally  only  is 
sleep  interfered  with.  As  a  rule  the  spasm  is  not  accom- 
panied by  pain.  A  dull  aching  sensation,  however,  is  some- 
times referred  to  the  afifected  muscles,  generally  the  upper 
part  of  the  trapezius  and  sternomastoid,  and  quite  frequently 
to  their  points  of  origin  on  the  occiput  and  mastoid  process. 
The  pain  is  much  like  a  fatigue  ache.  The  patient  may  have 
pain,  which  he- refers  to  the  back  of  the  neck  and  the  cervical 
spine,  and  sometimes  to  the  dorsal  spine ;  slight  sensitiveness 
to  pressure  may  be  met  with  in  these  regions. 

In  rare  cases  the  pain  is  referred  to  the  upper  part  of  the 
right  arm.  Once  in  a  while,  points  of  tenderness  may  be 
found  over  the  spinal  accessory  nerve.  Occasionally  pressure 
upon  such  a  point  arrests  the  spasm.  At  other  times  pressure- 
points,  not  painful  in  character,  such  as  are  met  with  in  facial 
spasm,  are  met  with  in  torticollis.  They  are  rare,  and  when 
they  exist  are  found  usually  over  the  spinal  accessory  nerve. 
Very  rarely  the  spasm  spreads  to  the  facial  muscles,  the 
platysma,  the  muscles  of  mastication,  and  even  to  the  muscles 
of  the  arms. 

TREATMENT. 

The  treatment  is  both  medical  and  surgical.  Drugs  yield 
no  definite  result.  Among  them  may  be  mentioned  antispas- 
modics such  as  bromids,  belladonna  and  cannabis  indica  and 
tonics  such  as  iron  and  arsenic.  Morphin,  as  in  the  case  of 
facial  spasm,  gives  decided  relief,  but  because  of  the  danger  of 
a  drug  habit,  it  is  not  to  be  used  except  in  extreme  cases,  and 
then  for  short  periods  of  time  only ;  e.g.,  when  the  spasm  is  so 
severe  as  to  prevent  sleep.  Fortunately  we  have  another  drug, 
gelsemium,  which,  while  not  giving  the  degree  of  relief  that 
morphin  does,  decidedly  mitigates  the  symptoms,  and  does 


638  DISEASES    OF   THE    NERVOUS    SYSTEM. 

this  without  the  formation  of  a  habit.  It  is  a  depressing 
remedy,  and  should  be  given  with  great  care.  The  treatment 
should  be  started  with  1-  or  2-  drop  (0.06  or  0.12  mil)  doses  of 
the  '  fluidextract,  given  at  intervals  of  four  hours.  Very 
gradually  the  dose  can  be  increased  up  to  5,  10,  or  15  drops 
(0.30,  0.60,  or  0.92  mil).  More  than  20  drops  (1.25  mils)  at 
one  dose  should  not  be  given.  The  patient  should  be  closely 
watched  while  taking-  this  treatment,  and  if  ocular  signs,  such 
as  double  vision,  make  their  appearance,  the  treatment  should 
at  once  be  discontinued.  By  beginning  with  a  small  dose, 
tolerance  to  the  drug  is  established.  The  spasm  diminishes  to 
a  marked  extent,  and  in  some  cases  almost  ceases.  The  relief 
is  so  great  that  it  adds  much  to  the  comfort  of  the  patient,  and 
the  improvement  usually  continues  for  some  time  after  the 
drug  is  discontinued.  It  is  a  good  plan  whenever  possible  to 
give  a  patient  at  the  same  time  a  course  of  full,  rest  treatment. 
The  affection  occurs  most  frequently  in  women  who  are  neu- 
rasthenic, and  who  are  therefore  greatly  benefited  in  general 
health  by  rest  treatment;  further,  if  gelsemium  be  used  while 
the  patient  is  resting,  the  greatest  amount  of  benefit  is  secured. 
Electricity,  it  should  be  added,  is  practically  useless. 

In  very  severe  cases,  surgical  interference  must  be  con- 
sidered. In  a  large  number  of  instances  the  spinal  accessory 
nerve  has  been  cut,  stretched  or  resected.  Great  improvement 
follows  such  treatment,  but  as  a  rule  the  spasm  returns  after 
a  number  of  weeks  or  months,  though  with  lessened  severity. 
More  extensive  operations  have  been  practised ;  but  when  we 
consider  that  at  least  ten  muscles  can  be  named,  in  addition 
to  the  sternomastoid  and  trapezius,  that  are  concerned  in 
rotation,  we  can  hardly  expect  surgery  to  cure  the  patient ;  the 
best  result  will  probably  be  a  more  or  less  marked  im- 
provement. 

Now  and  then  the  spasm  of  the  muscles  of  rotation  is 
bilateral.  It  is  seen  almost  exclusively  in  children,  in  whom  it 
is  commonly  the  result  of  dental  irritation.  If  the  muscles  of 
the  two  sides  act  simultaneously,  there  is  a  movement  as  of 
bowing,  which  is  repeated  at  short  intervals.  If  the  muscles 
of  the  two  sides  act  alternately,  the  head  is  constantly  rolled 
from  side  to  side.  Pain  does  not  accompany  the  affection,  but 
it  is  very  distressing  to  the  family.    Occasionally  a  very  bril- 


SPASMODIC   TORTICOLLIS.  639 

liant  result  is  obtained  by  lancing-  the  gums.  If  this  measure 
fails,  other  peripheral  irritation  should  be  looked  for,  special 
attention  being  paid  to  the  intestinal  tract. 

At  times,  the  spasm  which  affects  the  muscles  of  the  neck 
is  tonic  in  character,  the  head  being  held  firmly  in  one  posi- 
tion. As  a  rule,  the  neck  is  bent  to  one  side,  while  the  occiput 
is  drawn  backward,  and  the  whole  head  somewhat  rotated,  the 
position  varying  as  the  action  of  the  trapezius  or  of  the  sterno- 
mastoid  predominates.  This  affection  may  be  the  result  of 
irritation  of  deep  structures,  such  as  disease  of  the  cervical 
spine  or  meninges.  In  such  cases  other  symptoms  should  be 
present,  though  frequently  the  cause  cannot  be  determined.  It 
should  not  be  confused  with  rheumatism  of  the  muscles  pro- 
ducing ordinary  wry-neck.  The  treatment  must  be  based  on 
the  cause,  when  the  latter  can  be  discovered.  If  no  cause  can 
be  found,  counterirritation  over  the  cervical  spine  may  be 
practised,  together  with  the  administration  of  sedatives.  If  the 
case  fails  to  yield,  surgical  intervention  may  prove  of  benefit. 
Thus,  tendons  may  be  cut  and  the  head  secured  in  the  normal 
position  by  means  of  a  properly  constructed  apparatus.  The 
treatment  of  such  a  case  becomes  essentially  orthopedic.  Ex- 
tension of  the  cervical  spine  may  also  be  practised  with 
advantage.  Surgical  intervention  should  not  be  too  long 
delayed,  as  the  tendency  is  for  the  head  to  become  per- 
manently fixed  in  an  abnormal  position. 

Masticatory  Spasm.  Among  the  rarer  forms  of  myospasm 
is  masticatory  spasm.  It  is  occasionally  met  with  in  hysteria. 
Very  rarely  it  exists  as  an  independent  affection.  Under  such 
circumstances  it  is  due  to  some  peripheral  irritation  such  as 
caries  of  the  teeth,  neuralgia,  or  some  irritation  of  one  of  the 
sensory  branches  of  the  fifth.  Very  rarely,  lesions  in  distant 
parts,  such  as  the  extremities,  are  followed  by  this  curious 
affection.  Irritation  of  the  intestinal  tract  also  should  not 
be  forgotten.  If  hysteria  has  been  eliminated,  the  teeth 
and  the  body  generally  should  be  carefully  explored. 
If  a  rheumatic  cause  be  suspected,  the  salicylates  should 
be  administered.  If  no  cause  be  discovered,  electricity, 
moist  heat,  counterirritation  to  the  back  of  the  neck  or  mastoid 
regions  may  be  employed ;  and  in  children  a  vermifuge  may 
be  tried. 


640  DISEASES    OF   THE    NERVOUS    SYSTEM. 

Myoclonus.  Paramyoclonus  Multiplex.  This  affection 
was  originally  described  by  Friedreich  in  1881.  It  manifests 
itself  by  sudden,  lightning-like  clonic  spasms  involving  the 
muscles  of  the  trunk  and  extremities ;  the  facial  muscles  are 
rarely  involved.  The  spasms  attack  the  muscles  of  both  sides 
of  the  body  about  equally,  though  it  rarely  happens  that  the 
corresponding  muscles  of  the  two  sides  contract  at  the  same 
time.  The  attacks  come  on  in  paroxysms  which  last  for  sev- 
eral minutes.  The  clonus  is  rhythmic,  though  its  rate  varies 
considerably.  No  seizures  occur  during  sleep.  Voluntary 
motion  may  inhibit  or  lessen  them.  The  tendon  reflexes  are 
usually  increased.  Motor  power  is  intact.  Sensibility  appears 
to  be  normal.  The  mental  condition  is  normal.  The  affection 
usually  occurs  during  adult  life.  A  peculiar  form  of  myo- 
clonus has  been  described  by  Unverricht,  occurring  in  families, 
and  bearing  a  distinct  relation  to  epilepsy. 

The  important  matter  in  all  cases  of  myoclonus  is  the  dif- 
ferential diagnosis  from  hysteria.  Hysterical  myoclonus,  of 
course,  offers  a  good  prognosis.  True  Friedreich's  paramyo- 
clonus is  a  chronic  disease,  which  offers  little  prospect  of  cure. 
No  pathologic  lesions  have  been  found  to  account  for  the  affec- 
tion. Spasmodic  phenomena  resembling  myoclonus,  it  may  be 
mentioned,  have  been  observed  in  animals  deprived  of  their 
parathyroid  glands. 

In  the  way  of  treatment,  bromids,  arsenic,  galvanic  and 
static  electricity  may  be  employed.  Small  doses  of  thyroid 
extract  are  supposed  to  have  been  effective  occasionally.  The 
general  physiologic  methods  already  considered  under  neuras- 
thenia and  hysteria  should  be  thoroughly  applied  in  these 
cases. 

Saltatoric  Spasm.  In  saltatoric  spasm,  as  originally 
described  by  Bamberger,  the  patient  passes  through  a  series  of 
springing,  jumping,  hopping  or  dancing  movements  whenever 
he  attempts  to  walk,  the  movements  usually  beginning  as  soon 
as  the  feet  are  placed  upon  the  ground.  The  movements  are 
absent  in  bed.  Hysterical  stigmata  are  usually  present,  and 
the  affection  does  not  constitute  a  clinical  entity,  but  is  only 
one  of  the  motor  manifestations  of  hysteria.  The  prognosis  is 
good,  and  the  treatment  is  that  of  hysteria. 


THE    OCCUPATION    NEUROSES.  641 

THE    OCCUPATION    NEUROSES. 

The  characteristic  symptom  of  the  occupation  neuroses  is 
spasm  induced  by  the  performance  of  certain  and  frequently 
repeated  movements  or  actions.  This  form  of  myospasm  is 
most  frequently  met  with  as  writers'  cramp  or  scriveners' 
palsy.  To  this  group  are  to  be  added  the  occupation  cramps  of 
telegraphers,  pianists,  shoemakers,  milkers,  or  those  of  other 
occupations  which  call  for  the  habitual  performance  of  cer- 
tain movements.  The  direct  cause  of  the  disturbance  is  over- 
use and  overexertion.  However,  it  is  generally  evident  that 
the  patient  attacked  is  nervously  predisposed,  is  neurasthenic, 
or  is  in  general  ill  health.  Sometimes  more  than  one  individ- 
ual of  the  same  family  suffer  from  the  affection. 

In  most  cases,  the  patient  at  first  feels  only  fatigue  in  the 
performance  of  the  movement,  e.g.,  in  writing.  There  is  a  lack 
of  control  over  the  pen ;  the  pen  tends  to  stop  or  stick  to  the 
paper;  and  the  cramp  of  the  muscles  finally  develops  until 
motion  of  the  pen  is  impossible.  Again,  the  pen  may  fall  from 
the  hand  because  of  the  finger  being  cramped  in  extension. 
However,  the  flexors  of  the  thumb,  forefinger  and  middle 
finger  are  the  muscles  mainly  involved.  Later,  the  wrist  and 
forearm  may  l:>e  affected,  and  the  patient  may  complain  of  pain 
or  aching  in  the  hand,  sometimes  of  weakness  or  tremor.  The 
condition  may  be  so  severe  that  the  mere  act  of  grasping  a 
pen  may  bring  on  a  cramp.  The  hand  and  arm  are  entirely 
normal  for  other  movements,  and  it  seems  probable  that  the 
s^^mptoms  are  directly  due  to  an  exhaustion  of  the  neuromus- 
cular mechanism  concerned  in  writing. 

TREATMENT. 

The  treatment  should  consist  of  a  change  in  occupation. 
Frequently  this  cannot  be  carried  out,  and  in  mild  or  begin- 
ning cases  the  patient  is  unwilling  or  unable  to  abstain  entirely 
from  writing-,  and  in  such  cases  it  is  imperative  to  advise  the 
patient  as  to  the  manner  in  which  the  continuation  of  writing 
will  prove  least  harmful.  In  such  cases  writing  should  be 
performed  by  full  arm  and  shoulder  movements,  and  not  by 
the  fingers  and  hand.  The  hand  should  not  rest  upon  the 
paper.    Again,  the  handle  of  the  pen  may  be  thrust  through  a 

41 


642  DISEASES    OF   THE    NERVOUS    SYSTEM. 

cork,  large  and  conveniently  rounded,  and  the  latter  grasped 
by  the  palm  and  the  base  of  the  thumb  and  fingers.  Many 
patients  can  write  more  easily  with  a  lead  pencil  or  quill  than 
with  a  steel  pen.  In  short,  anything  which  changes  the  detail 
of  the  co-ordinations  required  is  helpful. 

Treatment  should  also  be  directed  toward  the  general 
health.  The  relation  to  neurasthenia  and  neuropathic  con- 
ditions is  often  so  obvious  that  general  rest  and  physiologic 
methods  are  indicated,  and  for  these  the  reader  is  referred  to 
the  section  on  Partial  Rest  Treatment.     (See  p.  583.) 

Tonics  such  as  iron,  arsenic  and  quinin  are  indicated. 
Local  treatment  by  electricity  and  massage,  while  not  very 
effectual,  are  of  some  benefit,  and  encourage  the  patient  by 
suggestion.  That  the  fatigue  is  central  and  not  local  is  shown 
by  the  fact  that  should  the  patient  train  his  left  hand  to  take 
the  place  of  the  right,  the  left  will  also  become  subject  to  the 
cramp.  General  exercises,  not  too  fatiguing,  may  be  per- 
mitted, but  these  had  best  be  taken  along  with  other  physio- 
logic methods  indicated  under  Partial  Rest  Treatment.  The 
treatment  of  other  occupation  neuroses  embraces  the  applica- 
tion of  the  general  principles  here  indicated. 

MYASTHENIA    GRAVIS. 

Myasthenia  gravis  is  an  affection,  the  characteristic  feature 
of  which  is  a  paresis,  functional  in  character,  but  which  closely 
simulates  an  organic  palsy.  It  most  frequently  makes  its 
appearance  in  a  form  which  closely  simulates  true  bulbar 
palsy.  However,  instead  of  progressing  steadily,  as  does  true 
bulbar  palsy,  cases  of  bulbar  myasthenia  vary  from  time  to 
time  as  to  the  intensity  of  the  symptoms.  The  latter  may  dis- 
appear altogether  for  a  time,  and  some  cases  even  recover. 

Among  the  various  symptoms  we  find  difficulty  of  articula- 
tion, difficulty  of  swallowing,  ptosis,  diplopia,  weakness  of  the 
muscles  of  mastication,  and  weakness  of  the  muscles  supplied 
by  the  facial  nerve.  The  muscles  of  the  neck,  trunk  and 
extremities  may  be  involved.  There  may  even  be  difficulty  in 
breathing.  The  patients  l:)ecome  fatigued  with  extreme  readi- 
ness. There  is  no  muscular  wasting,  and  no  reaction  of 
degeneration.     However,  the  muscles  soon  become  exhausted 


MYASTHENIA   GRAVIS.  643 

to  faradic  stimulation,  the  responses  becoming  more  and  more 
feeble,  until  they  finally  disappear.  This  is  known  as  the 
myasthenic  reaction.  After  a  period  of  rest  the  muscles  again 
respond.  There  is  no  anesthesia  and  no  pain.  Mental  symp- 
toms are  likewise  absent.  Marked  improvement  may  ensue 
during  a  remission,  and  the  disease  may  be  months  in  reaching 
its  greatest  intensity. 

The  diagnosis  may  be  quite  difficult  in  a  first  attack. 
However,  the  course  of  the  symptoms,  the  occurrence  of 
remissions,  the  absence  of  fibrillary  tremors,  the  absence  of 
wasting  in  the  muscles,  the  absence  of  electrical  changes,  the 
presence  of  the  myasthenic  reaction,  and  the  extreme  ease 
with  which  fatigue  can  be  induced,  serve  to  establish  the 
diagnosis. 

The  anatomic  findings  in  the  nervous  system  are  negative. 
In  the  muscles,  however,  Weigert  noted  a  round  cell  infiltra- 
tion, this  infiltration  having  its  origin  apparently  in  disease 
of  the  thymus  gland.  These  observations  have  been  made  by 
other  investigators.  Further,  Buzzard  observed  round  cell 
infiltration,  not  only  in  the  muscles,  but  also  in  other  organs. 
He  does  not,  however,  regard  the  disturbance  of  the  muscle 
function  as  dependent  on  this  infiltration,  nor  does  he  con- 
sider the  relation  of  the  infiltration  to  disease  of  the  thymus 
as  established.  He  regards  the  muscle  symptoms  probably  as 
due  to  some  form  of  intoxication. 

TREATMENT. 

During  an  attack  the  patient  should  be  put  to  bed,  and 
every  precaution  taken  to  avoid  muscular  exhaustion.  The 
exhaustion,  it  should  be  remembered,  may  involve  the  muscles 
of  respiration,  and  lead  indirectly  to  death.  xA.s  much  food  as 
possible  should  be  administered,  preferably  milk  and  eggs. 
Sometimes  there  is  great  difficulty  in  swallowing,  so  that  solid 
food  can  be  taken  only  with  efi^ort,  and  at  times  not  without 
danger  to  life.  In  cases  in  which  the  difficulty  of  swallowing 
is  extreme,  nasal  feeding  should  be  tried. 

Massage  and  electricity,  so  useful  in  other  asthenic  states, 
are  here  inapplicable ;  they  still  further  fatigue  and  exhaust 
the  muscles.  Tonics,  especially  strychnin,  are  indicated. 
The    strychnin    should    be    given    hypodermically — in    small 


644  DISEASES    OF   THE   NERVOUS    SYSTEM. 

doses  at  first,  and,  if  well  borne,  should  be  carefully  increased. 
A  cautious  use  may  also  be  made  of  thyroid  extract.  Delille 
and  \'incent  believe  they  have  obtained  good  results  in  one 
case  from  the  use  of  pituitary  and  ovarian  extract.  Finally, 
it  would  seem  that  if  a  persistent  and  overacting  thymus  is 
really  the  cause  of  the  symptoms,  the  indication  is  to  remove 
the  gland.  However,  so  radical  a  procedure  would  here  be 
especially  dangerous,  as  cases  of  myasthenia  gravis  bear  anes- 
thetics badly. 

TETANY, 

Tetany  is  an  affection  which  manifests  itself  by  intermit- 
tent tonic  spasm  affecting  symmetrically  the  muscles  of  the 
extremities,  particularly  those  of  the  hands  and  forearms,  and 
causing  the  hands  to  assume  most  frequently  the  position  of 
the  "writing"  or  "obstetric"  hand.  The  disease,  as  a  rule,  is 
ushered  in  by  vague  pains,  a  general  sense  of  uneasiness,  and 
a  feeling  of  weakness  and  stiffness  in  the  muscles,  which  is 
generally  most  marked  in  the  arms.  The  prodromal  period  is 
short,  sometimes  only  a  few  hours.  Then  a  tonic  spasm  of 
the  muscles  comes  on,  beginning  in  the  fingers  and  spreading 
up  the  forearms  and  arms.  The  flexor  muscles  are  most 
affected.  The  thumbs  and  fingers  become  flexed — the  proxi- 
mal phalanges  flexed,  the  middle  and  distal  phalanges  ex- 
tended— so  that  the  hand  assumes  the  writing  or  obstetric 
position.  This  is  not,  however,  invariably  the  case.  In  rare 
instances,  the  hand  may  be  clenched  or  the  fingers  opened  out 
and  spread  apart;  exceptionally,  too,  the  spasm  is  limited  to 
a  single  finger.  Spasm  having  been  established  in  the  hand, 
the  wrist  next  becomes  flexed,  the  forearm  flexed  upon  the 
arm,  and  the  arm  adducted  to  the  trunk.  The  spasm  may 
also  involve  the  lower  extremities.  The  toes  become  flexed, 
the  foot  arched,  and  the  legs  extended  upon  the  thighs.  The 
muscles  of  the  trunk  and  neck  may  also  be  invaded.  Very 
rarely  the  muscles  of  mastication,  of  expression,  or  the 
muscles  of  the  eyes  are  involved.  The  tongue  may  be 
affected ;  and  as  the  patients  at  times  complain  of  difficulty 
in  swallowing,  it  would  seem  that  in  such  cases  the  con- 
strictors of  the  pharynx  also  participate.  Spasm  of  the  larynx 
is  a  not  infrequent  and  serious  accompaniment  of  tetany.    The 


TETANY.  645 

involvement  of  the  muscles  is  almost  always  symmetrical ;  it 
may,  however,  be  more  marked  on  one  side,  and  cases  in  which 
it  has  been  limited  to  one  side  have  been  described. 

The  attack  of  spasm  comes  on  gradually.  It  may  last  for 
a  few  minutes  or  several  hours,  and,  in  rare  instances,  even 
days.  During  its  height  the  affected  muscles  become  very 
firm  and  hard,  and  somewhat  sensitive  to  pressure.  The 
spasm  may  recur  on  the  same  day,  the  next  day,  or  after 
several  days,  and  during  the  interval  the  patient  feels  quite 
well,  save  that  he  may  complain  of  slight  pain  and  stiffness 
in  the  muscles.  The  degree  of  spasm  varies  from  one  so  slight 
that  the  patient  may  be  able  temporarily  to  overcome  it,  to 
one  so  severe  that  the  arm,  for  instance,  is  firmly  held  in 
contracture. 

Besides  the  spasm,  which  is  the  most  striking  symptom  of 
tetany,  there  are  present,  as  a  rule^  other  important  signs. 
These  consist  especially  of  the  Trousseau,  the  Chvostek,  and 
the  Erb  symptoms.  Trousseau's  symptom  consists  of  the 
fact  that  the  spasm  may  be  brought  on,  if  absent,  or  made 
more  pronounced,  if  present,  by  pressure  upon  or  constriction 
of  an  affected  extremity.  If  during  a  passive  interval  the  arm 
be  grasped  so  that  the  large  nerve  trunks  and  blood-vessels  be 
compressed,  the  characteristic  cramp  sooner  or  later  makes  its 
appearance.  This  S3'mptom  when  present  establishes  the  diag- 
nosis of  tetany.  Unfortunately  it  is  absent  in  about  one-fourth 
to  one-third  of  the  cases.  Chvostek's  symptom  consists  of  an 
extraordinary  susceptibility  of  the  peripheral  nerves  to 
mechanical  stimuli.  Thus,  by  striking  the  7th  nerve  in  front 
of  the  ear  a  light  blow,  we  observe  twitching  of  the  facial 
muscles ;  most  frequently  we  see  movements  merely  of  the 
angle  of  the  mouth.  At  times  this  symptom  may  also  be 
observed  in  the  nerves  of  the  extremities.  Unlike  Trousseau's 
symptom,  it  is  not  pathognomonic  of  tetany.  It  is  occasion- 
ally elicited,  however,  when  there  are  no  other  evidences  of 
the  disease.  Erb's  symptom  consists  of  a  greatly  exaggerated 
electric  excitability  of  the  nerves.  Very  weak  currents — e.g., 
0.1  to  0.7  milliampere  (Pineles) — induce  cathodal  closure  con- 
tractions, Ca  CI  C ;  slightly  stronger  currents,  cathodal  closure 
tetanus,  Ca  CI  Te ;  An  CI  C  and  x\n  O  C  follow  readily.  An 
CI  Te,  Ca  O  C,  and  even  Ca  O  Te  are  observed. 


646  DISEASES    OF   THE   NERVOUS    SYSTEM. 

Hoffman's  symptom,  less  important  than  the  others,  con- 
sists of  an  increased  mechanical  and  electrical  excitability  of 
sensory  nerves.  Spontaneous  pains,  however,  are  also  present, 
variable  in  degree.  They  are  referred  especially  to  the  muscles 
affected  by  the  contracture.  Paresthesia,  e.g.,  formication, 
slight  numbness,  is  often  complained  of.  Anesthesia  is  not 
present.  The  reflexes  are  usually  normal ;  they  may,  however, 
be  plus  and  rarely  minus.  In  the  neighborhood  of  the  joints 
edema,  redness,  herpes  and  urticaria  have  been  noted.  Rarely, 
falling  out  of  the  hair  and  nails,  or  transverse  marking  of  the 
nails,  accompanies  this  disease.  Ad^uscular  atrophy  has  been 
noted,  though  it  is  unusual.  Excessive  sweating,  duskiness 
and  cyanosis  of  the  extremities,  and  also  puffiness  of  the  face 
and  swelling  of  the  eyelids  may  be  observed. .  Changes  in 
temperature  are  rare,  but  temperatures  both  above  and  below 
normal  have  been  noted.  Respiration  is  unaffected.  Very  fre- 
quently mental  symptoms  are  present;  in  each  case  they  are 
those  of  exhaustion  and  confusion.  An  attack  of  tetany  usu- 
ally lasts  several  weeks.  Rarely,  it  consists  of  only  a  few 
paroxysms.  Again,  it  may  last  for  months,  though  more  or 
less  prolonged  remissions  may  be  present. 

The  prognosis  on  the  whole  is  favorable.  No  fatal  case  of 
idiopathic  tetany  without  complications  has  been  observed. 
When  dilatation  of  the  'stomach  is  present,  however,  the  out- 
look may  be  very  serious.  Further,  in  the  tetany  that  is 
observed  after  thyroid  and  parathyroid  extirpation,  the  out- 
look is  very  serious. 

It  is  probable  that  tetany  is  the  result  of  some  infection. 
It  appears  to  be  favored  by  bad  hygienic  surroundings. 
Though  rare  in  this  country,  it  is  quite  common  in  some 
cities  of  Europe,  e.g.,  Vienna,  and  not  infrequently  occurs  in 
epidemic  form.  The  fact  that  tetany  results  from  removal 
of  the  parathyroid  glands  suggests  an  intimate  relation  be- 
tween these  glands  and  the  disease.  However,  tetany  seems 
to  be  of  varied  origin,  and  it  is  exceedingly  probable  that  it 
may  be  the  indirect  result  of  various  toxins;  possibly  of  the 
action  of  these  toxins  on  the  parathyroid  bodies.  Thus  it 
occasionally  follows  infectious  fevers,  such  as  measles,  scarlet 
fever  and  influenza.  At  other  times  it  is  associated  with 
gastro-intestinal  disturbances,  indigestion,  diarrhea,  dilatation 


PARALYSIS    AGITANS.  647 

of  the  stomach,  or  worms  in  the  intestine.  Pregnancy  and 
lactation,  it  should  be  added,  appear  greatly  to  increase  the 
susceptibility  to  the  disease. 

TREATMENT. 

The  patient  should  have  absolute  rest  in  bed.  The  diet 
should  consist  largely  of  milk  and  veg"etables.  Soups,  broths 
and  meats  should  be  avoided.  Tea  and  cofifee  should  be 
excluded.  AVarm  baths  may  be  used  to  allay  the  spasm  and 
increase  elimination.  Extract  of  thyroid  and  parathyroid 
g-lands  has  been  found  of  no  value.  Bromids  and  chloral 
in  full  doses  may  be  given  to  lessen  the  spasm.  Antipyrin, 
phenacetin  or  some  of  the  salicylates  may  be  employed  if  there 
be  much  pain.  If  the  attack  is  attended  by  gastric  dilatation, 
the  treatment  should  be  directed  against  the  disease  of  the 
stomach.  Thorough  lavage,  rectal  feeding  and  other  expedi- 
ents are  indicated.  Intestinal  antisepsis  should  also  as  far  as 
practicable  be  brought  about. 

The  hygienic  surroundings  of  patients  w^ith  tetany  should 
be  carefully  considered.  The  patients  should  have  abundant 
fresh  air,  and  should  not  be  exposed  to  cold.  In  cases  with  a 
tendency  to  recurrence,  a  change  of  residence  may  be  bene- 
ficial. Mothers  who  suffer  from  tetany  during  lactation 
should  not  nurse  their  children. 

PARALYSIS    AGITANS. 

Paralysis  agitans,  or  Parkinson's  disease,  is  an  affection 
which  manifests  itself  by  a  tremor,  usually  passive  in  char- 
acter, by  a  tendency  to  fixation  in  posture,  by  rigidity  of 
muscles,  and  by  a  peculiar  propulsive  gait. 

The  etiology  of  the  disease  is  unknown.  It  usually  makes 
its  appearance  in  the  latter  half  of  life ;  less  frequently  it  is 
noted  in  relatively  young  individuals.  Men  appear  to  suffer 
somewhat  more  frequently  than  women.  A  great  variety  of 
causes  have  been  assigned ;  e.g.,  grief,  worry,  mental  strain, 
shock  and  overexertion. 

Nothing  is  definitely  known  of  the  pathology  of  the  disease. 
The  changes  found  at  autopsy  are  largely  those  found  in  old 
age ;  such   as   arteriosclerosis   and   associated   changes   in   the 


648  DISEASES    OF   THE    NERVOUS    SYSTEM. 

nerve  centers.  The  recent  findings  by  Ramsey  Hunt  of  exten- 
sive changes  in  the  basal  ganglia,  apparently  degenerative  in 
their  nature,  are  very  suggestive  as  regards  the  symptoms, 
but,  on  the  other  hand,  the  positions  and  rigidity,  especially 
of  the  hands  and  arms,  remind  one  of  similar  phenomena 
resulting  from  parathyroid  extirpation,  and  suggest  the  pos- 
sibility of  parathyroid  disease. 

The  disease  comes  on  gradually.  It  may  be  preceded  by 
pains,  paresthesia  or  fatigue  sensations.  The  first  decided 
symptom  is  tremor.  This  usually  begins  in  the  hand  and 
fingers  of  one  side.  Very  frequently  it  begins  in  the  foot.  At 
first  it  may  be  slight  and  not  persistent.  However,  in  time  it 
becomes  established,  and  is  almost  constant.  Soon  rigidity 
appears  in  the  muscles,  together  with  weakness  and  slowing  of 
movements.  The  tremor  having  begun  in  the  arm  of  one 
side  may  spread  to  the  leg  on  the  same  side ;  or  it  may  first 
involve  the  opposite  hand  and  fingers,  so  that  both  arms  are 
afifected  before  the  tremor  is  noted  to  any  degree  in  the  legs. 
The  patient  stands  or  remains  seated  in  a  fixed  position.  The 
face  is  wooden  or  mask-like,  the  trunk  is  inclined  forward,  the 
arms  somewhat  adducted,  the  forearms  partially  flexed,  the 
hands  and  wrists  moderately  flexed  or  extended,  while  the 
fingers  assume  the  position  of  the  writing  hand.  The  motion 
of  the  thumb  and  fingers  suggests  pill-rolling.  While  the 
tremor  is  most  marked  in  the  extremities,  it  may  also  involve 
the  head,  the  jaw,  the  lips  and  the  tongue. 

The  tremor  is  passive,  that  is,  it  persists  while  the  part  is 
at  rest,  and  is  temporarily  arrested  by  voluntary  motion.  In 
all  his  movements  the  patient  is  slow.  Again,  in  walking  he 
very  frequently  shows  a  tendency  to  propulsion ;  he  leans 
forward,  his  steps  are  short,  and  he  may  even  be  forced  to  run. 
He  may  fall  unless  he  is  able  to  catch  hold  of  some  support. 
If  in  walking  he  turns  around,  the  head  and  trunk  turn  as  one 
piece,  as  in  a  statue.  As  the  disease  progresses,  the  rigidity, 
fixation  and  muscular  weakness  become  more  pronounced 
until  the  patient  is  forced  to  remain  in  his  chair  or  bed, 
physically  helpless. 

There  are  no  sensory  losses.  The  tendon  reflexes  are  nor- 
mal or  slightly  exaggerated.  There  is  no  ankle  clonus  or 
Babinski  sign.     Mental  disturbances  are  rare,  but  mild  con- 


FUNCTIONAL   TREMORS.  649 

fusion  or  depression  may  make  their  appearance  late  in  the  dis- 
ease. The  patient  may  be  slow  in  answering  questions,  or  the 
words  may  come  quickly  or  in  an  explosive  utterance.  The 
disease  is  of  long  duration;  fifteen  or  twenty  years  are  not 
uncommon.  Death  results  from  exhaustion  or  visceral  com- 
plications. 

TREATMENT. 

Paralysis  agitans  is  one  of  the  few  diseases  in  which  rest 
treatment  is  not  applicable.  If  possible,  the  patient  should 
lead  a  quiet  life,  preferably  in  the  country,  free  from  mental 
and  physical  strain.  Simple  and  abundant  food  and  a  full 
amount  of  sleep  are  of  course  indicated.  Gentle  but  sys- 
tematic exercises  should  be  instituted  and  persisted  in.  The 
patient  usually  enjoys  gentle  movement,  though  from  the 
nature  of  his  affection  he  tends  to  remain  quiet.  The  exercise 
should  be  active  or  passive,  according  to  the  case,  and  should 
embody  the  principle  of  precision,  as  in  those  devised  by 
Frankel  for  the  treatment  of  tabetics.  The  tendency  of  the 
patient  is  to  a  gradually  increasing  fixation,  and  this  the  exer- 
cise seems  to  delay.  The  mere  fact  of  being  in  motion  has  a 
good  psychic  effect  on  the  patient.  Thus  he  feels  better  when 
he  is  seated  in  a  train,  or  in  an  automobile.  Sometimes  a 
woman  patient  will  take  great  comfort  from  the  continuous 
use  of  a  rocking  chair.  Other  therapeutic  procedures,  such  as 
massage  and  electricity,  are  as  a  rule  badly  borne.  This  is 
also  true  of  hydrotherapy. 

Medicines  are  of  little  value.  The  occasional  use  of  the 
bromids  may  be  permitted  to  relieve  depression  temporarily. 
Hyoscin  or  scopolamin  %,)o  grain  (0.00033  Gm.)  three  times 
daily  somewhat  lessens  the  tremor,  but  fails  after  a  wliile. 

Parathyroid  extract  %q  to  i/i,,  grain  (0.003  to  0.006  Gm.) 
three  times  daily,  is  also  of  temporary  benefit  in  diminishing 
the  tremor ;  it  loses  its  effect  in  ten  days  or  two  weeks.  Tonics 
are  occasionally  useful.  Strychnin,  for  obvious  reasons, 
should  not  be  given. 

FUNCTIONAL    TREMORS. 

Among  functional  tremors,  we  must  distinguish  the 
tremors  of  neurasthenia,  of  hysteria,  hereditary  or  familial 
tremors,  senile  tremor,  and,  finally,  a  tremor  classifiable  under 


650  DISEASES    OF   THE    NERVOUS    SYSTEM. 

none  of  these  heads,  which  is  observed  from  time  to  time  in 
neuropathic  individuals.  The  tremors  of  neurasthenia  and 
hysteria  have  already  been  considered.  Hereditary  or  familial 
tremor  is  a  rather  rare  affection,  the  cause  of  which  is 
unknown.-  Frequently  the  family  histoi-y  is  entirely  free  of  a 
neuropathic  taint.  Occasionally,  we  meet  a  history  of  alco- 
holism, mental  disease  or  epilepsy  in  the  ancestry.  It  affects 
both  sexes  equally  and  is  transmitted  by  males  and  females 
alike.  It  usually  appears  in  youth ;  rarely  does  it  begin  at  a 
more  advanced  age.  It  is  characterized  by  rhythmic  move- 
ments, of  small  extent,  which  vary  from  about  three  to  nine 
in  a  second.  In  type  it  is  an  intention  tremor,  though  in  some 
cases  it  is  present  in  a  less  pronounced  form  during  rest. 
Occasionally  it  may  be  suppressed  for  a  time  by  the  will  of 
the  patient;  it  becomes  exaggerated  during  voluntary  move- 
ments and  during  effort.  It  is  most  frequently  seen  in  the 
hands,  less  frequently  in  the  feet,  and  rarely  in  the  face,  the 
tongue  or  the  head.  Sometimes  it  becomes  more  marked  with 
advancing  age ;  in  other  cases  time  produces  little  change. 
Sometimes  there  are  remissions;  infrequently  it  disappears. 
The  disease  is  transmitted  from  generation  to  generation,  and 
is  often  present  in  several  members  of  the  same  generation.  It 
is  not  deleterious  to  life,  and  does  not  interfere  with  the 
patient's  occupation  except  in  those  cases  in  which  it  becomes 
more  marked  as  time  passes.  It  is  made  worse  by  fatigue,  and 
improves  with  rest. 

Senile  tremor  affects  chiefly  the  head  and  arms ;  It  is  a 
tremor  of  small  extent,  which  is  increased  by  voluntary  move- 
ments, and  which  almost  or  entirely  disappears  during  rest. 
It  is  not  influenced  by  treatment. 

Simple  idiopathic  or  neuropathic  tremor  is  not  a  frequent 
affection  and  appears  to  be  allied  to  the  myokymias  and  tics. 
It  is  found  mostly  in  patients  neuropathically  predisposed.  It 
generally  attacks  the  hands  and  head,  and  less  frequently  the 
muscles  of  the  face  and  tongue.  It  is  a  fine  tremor,  diminishes 
during  rest,  and  is  made  worse  by  voluntary  motion  or  excite- 
inent.  Sometimes  patients  attribute  the  tremor  to  fright  or 
shock.  Occasionally  it  disappears  for  a  time ;  more  often  it  is 
persistent.  It  rarely  causes  the  patient  any  annoyance^  and 
4oes  not  respond  to  treatment. 


DISEASES    OF   THE    DURA    MATER.  651 


PART   II. 

ORGANIC  DISEASES  OF  THE  NERVOUS 
SYSTEM. 

In  the  treatment  of  organic  nervous  diseases,  the  general 
principles  considered  in  the  treatment  of  functional  nervous 
diseases  are,  of  course,  also  applicable  in  greater  or  less  degree. 
Rest,  massage,  exercise  in  so  far  as  it  may  be  practicable,  bath- 
ing and  feeding  are  equally  to  be  borne  in  mind.  That  the 
benefit  to  be  derived  from  these  procedures  is  much  less  pro- 
nounced goes,  of  course,  without  saying,  and  that  they  are 
most  productive  of  results  in  comparatively  mild  cases,  and 
more  especially  in  affections  of  the  cord,  peripheral  nerves  and 
muscles  is  equally  evident.  Nevertheless,  they  should  when- 
ever practicable  be  employed.  In  the  following  sections  the 
special  points  in  the  treatment  of  the  various  organic  affections 
have  been  briefly  stated.  Necessarily  the  therapeutic  results 
are  very  limited  when  compared  with  those  achieved  in  the 
field  of  the  functional  diseases. 

DISEASES  OF  THE  BRAIN  AND  ITS 
MEMBRANES. 

DISEASES    OF    THE    DURA    MATER. 

The  dura  mater  is  composed  of  2  layers;  an  inner  thin  layer 
covered  with  endothelium,  and  an  outer  thicker  layer,  which 
serves  as  the  periosteum  for  the  bones  of  the  skull.  Inflam- 
mation of  the  dura  mater  is  termed  pachymeningitis,  either 
external  or  internal  according  to  the  layer  involved. 

External  Cerebral  Pachymeningitis.  Inflammation  of  the 
outer  layer  of  the  dura  is  secondary  to  some  other  condition, 
such  as  trauma  to  the  head,  caries  of  the  cranial  bones  due  to 
syphilis,  middle  ear  disease,  or  infections  of  the  scalp,  e.g., 
erysipelas.  Sometimes  no  cause  can  be  found.  In  acute  cases, 
pus  may  form  between  the  dura  and  the  skull.  In  the  chronic 
or  fibrous  form,  adhesion  often  occurs  between  the  dura  and 
the  skull. 


652  DISEASES    OF   THE   NERVOUS    SYSTEM. 

The  symptoms  do  not  definitely  point  to  the  disease.  They 
consist  of  headache,  vertigo,  delirium,  and  perhaps  convul- 
sions, symptoms  that  are  present  in  many  other  affections. 
The  diagnosis  commonly  follows  the  recognition  of  the  other 
conditions  present. 

The  prognosis  in  the  acute  form  is  grave.  In  the  chronic 
form,  although  response  to  treatment  is  poor,  death  is  not 
likely  to  result. 

The  treatment  of  the  acute  form  is  almost  entirely  surgical. 
In  the  chronic  form,  especially  if  due  to  syphilis,  mercury  and 
iodids  are  indicated.  Counterirritation  at  the  back  of  the 
neck  may  be  employed.  These  means  failing,  surgical  treat- 
ment in  the  form  of  trephining  may  be  resorted  to. 

Internal  cerebral  pachymeningitis  may  be  met  with  in  two 
forms,  purulent  and  hemorrhagic.  Commonly  the  purulent 
form  is  merely  a  complication  of  a  purulent  infection  of  the 
outer  layer  or  of  the  pia,  and  need  not  further  detain  us  here. 
The  hemorrhagic  form  is  more  common ;  it  is  found  as  a  com- 
plication in  paretic  dementia,  senile  dementia,  and  chronic 
alcoholism.  It  may  occur  in  scurvy,  pernicious  anemia  and 
other  diseases  of  the  blood,  syphilis  (congenital  or  acquired), 
tuberculosis,  nephritis,  and  cardiac  disease ;  it  is  sometimes, 
although  rarely,  met  with  as  a  complication  in  the  exanthe- 
mata. Finally,  it  may  be  traumatic.  It  occurs  most  frequently 
in  males  and  in  those  of  advanced  years. 

Two  views  as  to  the  origin  of  pachymeningitis  hemor- 
rhagica are  held ;  first,  that  an  inflammatory  exudate  occurs, 
with  the  subsequent  rupture  of  vessels  in  this  exudate ;  second, 
that  a  hemorrhagic  exudation  takes  place,  with  subsequent 
organization  and  repeated  hemorrhages.  The  latter  seems  the 
more  plausible  explanation,  especially  when  it  occurs  as  a 
mere  trophic  disturbance,  e.g.,  in  paresis.  It  is  commonly  as- 
sociated with  atrophy  of  the  convolutions. 

The  symptoms  of  the  hemorrhagic  pachymeningitis  are  usu- 
ally vague  in  character,  and  are  met  with  as  complications  of 
other  conditions.  They  are  mainly  those  of  cerebral  pressure, 
and  are  slight  or  severe,  depending  upon  the  extent  of  the 
lesion.  The  patient  may  have  headache,  vertigo,  loss  of  mem- 
ory, and  possibly  stupor.  He  may  be  hemiplegic  or  hemi- 
paretic.    He  may  have  unilateral  convulsions. 


ACUTE    CEREBRAL   LEPTOMENINGITIS.  653 

The  diagnosis  may  be  impossible  because  of  the  underlying 
disease  with  which  the  pachymeningitis  is  associated,  and  on 
account  of  the  predominant  symptoms,  e.g.,  if  uremia  also  be 
present,  the  clinical  picture  relates  chiefly  to  this  intoxication. 
Often  the  diagnosis  can  only  be  conjectural.  In  senile  demen- 
tia or  in  chronic  alcoholism,  it  may  attain  a  certain  degree  of 
probability. 

The  prognosis  is  unfavorable,  both  from  the  standpoint  of 
the  disease  itself  and  from  that  of  the  diseases  with  which  it  is 
associated. 

The  treatment  is  necessarily  that  of  the  underlying  and  as- 
sociated conditions.  If  the  diagnosis  of  a  recent  hemorrhagic 
exudation  is  made — which  is  doubtful — it  may,  of  course,  be 
treated  symptomatically ;  for  example,  by  elevating  the  head 
and  applying  an  ice-cap.  Lumbar  puncture  and  trephining  are 
expedients  of  doubtful  value. 

ACUTE  CEREBRAL  LEPTOMENINGITIS. 

The  term  signifies  an  acute  inflammation  of  the  pia-arach- 
noid  covering  the  brain.  The  causes  are  to  be  sought  in  bac- 
terial infections;  e.g.,  streptococcus,  pneumococcus,  bacillus 
tuberculosis,  the  spirillum  of  syphilis,  the  gonococcus,  and  the 
diplococcus  intracellularis.  It  may  be  the  sequel  of  some  acute 
infectious  disease,  especially  of  pneumonia,  of  which  it  is  not 
an  uncommon  complication.  It  may  arise  from  middle  ear 
disease,  and  affections  of  the  nose,  throat,  nasal  sinuses,  and 
tonsils.  A  brain  abscess  also  may  reach  the  surface,  and  thus 
cause  meningitis.  It  is  met  with  most  frequently  in  the 
young. 

There  is  an  intense  cellular  infiltration  of  the  pia-arach- 
noid,  the  cells  being  chiefly  mononuclear  in  syphilitic  and  tu- 
bercular forms,  and  polynuclear  in  the  purulent  varieties.  If 
the  process  lasts  a  sufficient  time,  the  membranes  and  blood- 
vessels are  thickened,  and  small  hemorrhages  may  be  found 
in  the  membranes.  The  brain  cortex  may  be  softened  and 
contain  hemorrhagic  foci. 

Prodromal  symptoms  of  languor,  headache,  vomiting,  and 
fever  may  be  present.  The  attack  may  be  ushered  in  suddenly 
with  a  chill,  fever,  and  violent  and  persistent  headache.     De- 


654  DISEASES    OF   THE    NERVOUS    SYSTEM. 

lirium  soon  is  manifest,  and  in  severe  cases  is  followed  by 
stupor.  Retraction  of  the  head,  rig-idity  of  the  muscles  of  the 
back  of  the  neck,  retraction  of  the  abdominal  muscles,  and  in- 
ability to  extend  the  leg-  on  the  thigh  when  thigh  is  flexed  on 
the  abdomen  (Kernig's  sign)  are  prominent  symptoms.  Pal- 
sies of  the  cranial  nerves  may  be  present,  and  point  naturally 
to  a  basilar  meningitis.  Muscular  twitchings  and  convulsions 
are  common,  the  latter  being  due  to  implication  of  the  motor 
areas.  Optic  neuritis  may  occur.  The  pupils  may  be  con- 
tracted or  dilated  and  unequal. 

With  a  clear  history  the  diagnosis  should  not  be  difficult; 
however,  the  toxins  of  the  infectious  diseases,  especially  ty- 
phoid fever  and  pneumonia  in  a  child,  may  cause  cortical  irri- 
tation closely  simulating  meningitis.  The  examination  of  the 
spinal  fluid  is  often  of  value  in  establishing  a  diagnosis. 

TREATMENT. 

The  patient  should  be  kept  quiet  in  bed,  and  the  bowels 
freely  opened,  preferably  with  calomel.  The  ice-bag  should 
be  applied  to  the  head.  Pain  must  be  controlled  by  bromids, 
acetphenetidin,  and,  if  necessary,  by  opium.  Benefit  may  be 
derived  from  lumbar  puncture.  If  the  patient  stands  drainage 
of  the  cerebrospinal  fluid  well,  the  lumbar  puncture  may  be 
repeated  with  benefit  every  second  or  third  day.  If  the  dis- 
ease has  its  origin  in  a  purulent  focus  in  some  other  part  of 
the  body  this  focus  must  also  be  treated. 

In  the  epidemic  form,  that  due  to  the  Diplococcus  intracellu- 
laris,  the  antiserum  developed  by  Flexner  should  be  used;  this 
should  be  injected  into  the  subdural  space.  If  the  spinal  fluid 
is  turbid  or  purulent  it  is  wise  to  use  the  antiserum  at  once 
and  not  to  wait  for  a  bacteriologic  diagnosis.  The  antiserum 
must  be  kept  cold  until  ready  for  use,  and  after  it  has  been 
warmed  to  the  body  temperature,  15  to  45  mils  (4  to  12  fo) 
may  be  given  at  one  dose,  except  in  young  infants  when 
smaller  doses  should  be  used.  The  injections  may  be  repeated 
daily  for  several  days,  according  to  the  condition  of  the  patient 
and  the  findings  in  the  spinal  fluid.  So  long  as  meningococci 
are  found  the  injections  should  be  continued.  In  the  fulmin- 
ant and  very  severe  cases  the  injection  may  be  given  twice 
during  the  first  twenty-four  hours. 


BRAIN    ABSCESS.  655 

HYDROCEPHALUS. 

Hydrocephalus  is  characterized  by  an  increase — usually  a 
very  great  increase — in  the  amount  of  fluid  in  the  ventricles. 
So-called  external  hydrocephalus  occurs  as  a  condition  secon- 
dary to  brain  atrophy,  e.g.,  in  paresis,  and  does  not  demand 
special  consideration.  Internal  hydrocephalus  may  be  con- 
genital or  acquired. 

The  congenital  form  commonly  is  the  result  of  a  malforma- 
tion of  the  brain,  having-  its  origin  in  embryonic  life,  and  may 
be  complicated  with  porencephaly.  The  etiology  is  not  well 
understood,  but  occlusion  of  the  aqueduct  of  Sylvius  may  plav 
a  role  ;  at  other  times  it  may  be  due  to  disease  of  the  ependyma. 
Syphilis  is  the  underlying  cause  in  many  congenital  cases,  and 
alcohol  also  may  be  the  provocative  factor.  When  acquired  it 
may  be  due  to  any  cause  which  obstructs  the  outflow  of  fluid 
from  the  ventricles ;  for  instance,  a  basal  meningitis  or  a  tumor 
pressing  upon  the  aqueduct.  The  disease  may  be  present  at 
birth,  or  may  show  itself  within  the  first  year  of  life. 

The  characteristic  symptom  is  a  gradual  increase  in  the  size 
of  the  head,  which  in  some  cases  becomes  enormously  en- 
larged. The  fontanelles  bulge,  and  the  child  becomes  restless 
and  irritable.  The  eyes  are  prominent;  nystagmus,  strabis- 
mus, and  optic  atrophy  may  be  present.  The  child  may  or 
may  not  learn  to  walk  and  talk.  A  spastic  gait  may  develop. 
Convulsions  are  likely  to  occur.  The  outlook  is  bad,  except 
in  mild  cases. 

Treatment  is  very  unsatisfactory.  If  due  to  syphilis  results 
may  be  obtained  from  thorough  treatment.  There  is  also 
reason  to  believe  that  this  treatment  will  be  aided  b}-  svs- 
tematic  lumbar  puncture  and  drainage  of  the  cerebrospinal 
fluid.  Puncture  of  the  corpus  callosum  {halgenstich)  may  be 
resorted  to.  The  results,  however,  are  not  very  encouraging. 
The  removal  of  tumors,  e.g.,  of  the  pineal  gland,  compressing 
the  aqueduct  is  still  a  problem  confronting  the  surgeons. 

BRAIN    ABSCESS. 

Brain  abscess  is  caused  by  infection  carried  to  the  brain  in 
the  blood  stream,  or  by  the  extension  of  inflammation  from 
contiguous    infected    structures.      Abscesses   occur   most   fre- 


656  DISEASES    OF   THE    NERVOUS    SYSTEM. 

quently  in  the  cerebrum,  either  in  the  temporal  or  frontal 
lobes ;  those  due  to  ear  disease  usually  are  located  in  the  tem- 
poral lobe  or  in  the  cerebellum. 

The  symptoms  of  brain  abscess  may  run  either  a  rapid  or  a 
slow  course,  the  former  type  usually  following  trauma.  If 
there  are  no  focal  symptoms  the  clinical  picture  may  be  mis- 
taken for  meningitis.  The  focal  symptoms  when  present  are 
revealed  as  a  hemiplegia,  aphasia,  localized  convulsions,  or  by 
other  signs;  or  if  in  the  cerebellum,  by  incoordination  and 
other  cerebellar  symptoms.  Optic  neuritis  may  occur.  Death 
may  occur  in  a  few  days. 

The  chronic  form  usually  is  associated  with  ear  disease. 
The  symptoms  may  not  be  present  for  months  at  a  time.  The 
patient  may  suffer  from  headache  and  vertigo;  he  may  have 
acute  attacks  of  severe  headache,  and  vomiting  or  convulsions, 
and  apparently  regain  his  usual  health.  The  temperature  is 
normal  or  subnormal.  The  pulse  may  be  slow,  although  this 
change  is  not  met  with  as  frequently  as  in  brain  tumor.  In 
the  terminal  stage,  the  symptoms  may  assume  an  acute  char- 
acter or  there  may  be  epileptiform  seizures,  followed  by  coma 
and  death. 

The  diagnosis  often  is  difficult.  Much  depends  upon 
the  history  of  the  case,  and  inquiry  as  to  disease  of  the 
middle  ear  or  of  the  frontal  or  other  sinus  is  essential.  The 
temperature  remains  normal  or  subnormal  unless  there  is  an 
associated  meningitis.  Focal  symptoms  and  the  direct  evi- 
dence of  disease  of  the  ear  or  sinuses  are  of  great  value.  In 
the  differentiation  between  an  otitic  abscess  in  the  temporal 
lobe  and  cerebellum  the  Barany  method  may  be  of  value. 
(See  section  on  Vertigo,  p.  615.) 

The  outlook  is  discouraging.  The  treatment  is  necessarily 
surgical,  and  should  be  instituted  as  soon  as  the  diagnosis  can 
be  accurately  made.  In  very  rare  cases  the  abscess  empties 
itself  spontaneously,  as  through  the  nasal  passages.  One  of 
the  great  dangers  from  brain  abscess  is  the  development  of  a 
secondary  purulent  meningitis. 


CEREBRAL   ANEMIA.  657 

THROMBOSIS    OF   THE    CEREBRAL    SINUSES. 

Marantic  thrombosis  is  caused  by  general  disease  resulting- 
in  cardiac  weakness,  changes  in  the  coagulability  of  the  blood, 
and  injury  of  the  inner  wall  of  the  sinus. 

Inflammatory  thrombosis  is  the  result  of  septic  infection, 
usually  from  caries  of  the  petrous  portion  of  the  temporal 
bone.  This  leads  to  purulent  leptomeningitis,  extradural  ab- 
scess, and  brain  abscess. 

Marantic  thrombosis  usually  occurs  in  the  longitudinal  and 
transverse  sinuses.  The  consequences  are  congestion,  edema, 
and  hemorrhage  into  the  brain.  The  brain  being  enclosed  in 
a  rigid  bony  cavity,  the  arterial  flow  of  blood  will  decrease 
because  of  the  congestion  and  edema. 

Mental  dullness,  stupor,  and  coma  will  result;  and  at  times 
delirium,  convulsions,  and  palsies.  The  diagnosis  is  difficult, 
since  the  symptoms  resemble  meningitis. 

Thrombosis  of  the  transverse  sinus  may  show  edema  be- 
hind the  ear.  In  thrombosis  of  the  longitudinal  sinus  there 
may  be  engorgement  of  the  veins  passing  from  the  parietal  to 
the  temporal  region.  The  nose  may  bleed  freely  as  a  result  of 
the  congestion  of  the  veins  of  the  nose.  In  thrombosis  of  the 
cavernous  sinus  there  is  edema  of  eyelid  and  face ;  exophthal- 
mos, engorgement  of  retinal  veins,  and  edema  of  the  disc  may 
appear.  Paralysis  of  the  eye  muscles  and  neuralgia  may  be 
present.  Inflammatory  thrombosis  of  the  cavernous  sinus 
usually  is  caused  by  inflammations  of  the  orbit  and  face.  The 
diagnosis  is  made  more  certain  by  discovery  of  the  primary 
focus  of  infection. 

The  treatment  is  most  discouraging.  Marantic  thrombosis 
demands  rest,  and  treatment  of  the  anemia  or  other  general 
conditions.  After  the  thrombus  has  formed  little  can  be  done 
by  medication.  Purulent  thrombosis  demands  removal,  by 
operation,  of  the  part  of  the  sinus  aft'ected. 

CIRCULATORY  DISTURBANCES  OF  THE 

BRAIN. 
CEREBRAL    ANEMIA. 

For  a  long  time  the  symptoms  of  neurasthenia  were  errone- 
ously ascribed  to  cerebral  anemia.     True  cerebral  anemia  oc- 

42 


658  DISEASES   OF  THE   NERVOUS   SYSTEM. 

curs  merely  as  a  symptom  of  other  conditions.  Its  diagnosis 
as  an  independent  affection  is  practically  never  made  in  the 
modern  clinic. 

Anemia  of  the  brain  occurs  as  a  complication  in  diseases 
of  the  blood — chlorosis,  pernicious  anemia,  and  leukemia;  in 
cachectic  conditions;  in  inanition;  it  may  result  from  the  pres- 
sure of  a  brain  tumor  within  an  unyielding  skull,  from  the  sud- 
den dilatation  of  the  blood-vessels  in  other  portions  of  the 
body,  as  in  emotion  or  shock,  and  from  the  lowering  of  intra- 
abdominal pressure  by  the  removal  of  a  large  tumor  or  an  ex- 
tensive ascites;  from  sudden  and  grave  hemorrhage,  heart  fail- 
ure, or  other  causes  that  greatly  diminish  the  blood  supply  to 
the  brain. 

If  of  sudden  onset,  the  patient  complains  of  symptoms 
such  as  darkness  before  the  eyes,  vertigo,  tinnitus,  headache, 
and  muscular  twitching;  in  severe  cases  there  is  mental  tor- 
por, syncope,  and  loss  of  consciousness.  The  skin  becomes 
pale  and  cold,  and  the  heart's  action  rapid.  The  prognosis  is, 
of  course,  that  of  the  underlying  affection. 

The  treatment,  in  an  acute  case,  as  for  instance  in  an  ordi- 
nary fainting  spell,  consists  of  placing  the  patient  in  the  hori- 
zontal position  with  the  head  low.  Stimulants,  aromatic 
spirits  of  ammonia,  whisky  and  hot  water,  or  the  administra- 
tion of  strychnin,  digitalis,  or  atropin  may  be  indicated.  Hot 
coffee  may  be  given  by  the  rectum.  Stimulation  of  the  surface 
of  the  body  by  vigorous  friction,  slapping  with  a  wet  towel, 
and  sinapisms  to  the  epigastrium  may  aid  in  bringing  about  a 
reaction.  In  chronic  cases,  the  treatment  is  that  of  the  under- 
lying disease. 

CEREBRAL    HYPEREMIA. 

Like  cerebral  anemia,  hyperemia  of  the  brain  is  met  with 
in  practice  largely  as  a  complication  of  other  conditions,  par- 
ticularly disease  of  the  heart,  and  at  times  of  the  lungs.  Here 
the  congestion  is  passive  in  character.  It  is  possible  that 
active  hyperemia  occurs  as  a  complication  of  some  of  the  acute 
mental  disturbances,  but  the  latter  are  essentially  toxic  in 
origin.  It  occurs  possibly  also  as  a  result  of  large  doses  of 
quinin,  and  the  nitrites  also  have  a  direct  effect  in  bringing 
about  dilatation  of  the  vessels  of  the  brain.     The  amount  of 


CEREBRAL  APOPLEXY.  659 

blood  present  in  the  cranial  cavity  is  also  influenced  by  severe 
coughing,  such  as  that  excited  by  attacks  of  whooping-cough. 
Brain  tumor,  sinus  thrombosis,  and  pressure  upon  the  veins 
of  the  neck  have  a  similar  and  more  continuous  influence. 

Hyperemia  of  the  brain  is  probably  accompanied  by  symp- 
toms of  headache,  tinnitus,  vertigo,  by  a  sensation  of  fullness 
of  the  head,  and  possibly  by  epileptiform  attacks.  The  symp- 
toms are  made  worse  by  lying  down ;  as  a  whole,  however, 
they  form  a  very  subordinate  group  in  comparison  with  those 
of  the  underlying  disease. 

The  treatment  is  that  of  the  underlying  disease.  If  the 
symptoms  are  pronounced,  however,  they  may  demand  special 
attention.  In  such  case,  the  head  should  be  elevated,  and  cold 
applications  used.  A  hot  mustard  bath  of  the  feet  and  hands 
may  be  applied.  In  passive  congestion,  free  venesection  may 
be  indicated.  Mental  effort  and  excitement,  severe  coughing, 
and  straining  at  stool  should  be  avoided.  '  If  the  blood  pres- 
sure is  high,  it  should  be  gradually  reduced,  by  appropriate 
measures.  This  is  best  brought  about  by  a  restricted  diet, 
largely  of  milk,  and  by  the  living  of  a  quiet  life.  The  use  of 
the  iodids  in  small  doses  for  a  long  period  may  be  of  benefit. 
Ergot  has  been  recommended  on  theoretical  grounds,  but  it  is 
probably  of  little  use. 

CEREBRAL  APOPLEXY. 

The  term  apoplexy,  which  literally  means  a  striking  down, 
is  applied  to  the  symptoms  produced  by  embolism,  thrombo- 
sis, or  hemorrhage  of  the  brain ;  at  times  similar  symptoms 
are  noted  due  to  effusion  and  to  toxic  states. 

Disease  of  the  vessels  is  the  common  cause  of  hemorrhage 
and  of  thrombosis.  Embolism  is  usually  associated  with  acute 
or  chronic  endocarditis.  Among  exciting  causes  are  violent 
mental  or  physical  exercise,  over-eating  and  over-drinking, 
and  other  causes  which  raise  the  blood-pressure.  Transient 
apoplectiform  attacks  occur  in  paresis,  uremia,  and  at  times 
in  brain  tumor.  Changes  in  the  blood  that  make  for  excessive 
hematopexis,  together  v/ith  a  feeble  heart  action,  predispose 
to  thrombosis. 


660  DISEASES    OF   THE   NERVOUS    SYSTEM. 

In  general  terms,  arteriosclerosis  is  the  most  common  un- 
derlying lesion.  Any  causes  which  weaken  the  vessel  wall, 
such  as  an  endarteritis  or  periarteritis,  may  lead  to  rupture. 
Not  infrequently  a  periarteritis  leads  to  the  formation  of  small 
aneurisms,  so-called  miliary  aneurisms,  the  rupture  of  which 
gives  rise  to  hemorrhage.  Brain  hemorrhage  most  frequently 
takes  place  in  the  region  of  the  internal  capsule.  After  a 
hemorrhage,  a  clot  forms,  softens,  and  absorption  takes  place. 
Inflammation  in  the  tissues  about  the  clot  occurs,  and  may 
lead  to  the  formation  of  a  cyst,  or  instead  proliferation  of 
connective  tissue  with  the  formation  of  a  pigmented  scar 
may  result.  The  lesion  tears  in  greater  or  less  degree  the 
fibers  of  the  motor  pathway,  and  the  fibers  below  the  lesion 
degenerate.  If  an  artery  is  obstructed  by  a  thrombus  or  an 
embolus,  degeneration  and  softening  of  the  area  supplied  take 
place,  as  there  is  little  or  no  collateral  circulation  in  the  arter- 
ies of  the  brain.  If  the  area  be  small  it  may  gradually 
become  absorbed;  if  large,  inflammation  of  the  sur- 
rounding tissue  may  lead  to  the  formation  of  a  retaining 
wall  and  a  cyst.  If  an  embolus  arises  from  some  infected 
source,  such  as  a  septic  endocarditis,  a  brain  abscess  is  to  be 
anticipated. 

The  symptoms  of  hemorrhage,  embolism,  and  thrombosis 
so  closely  resemble  each  other  as  to  render  a  differential  diag- 
nosis very  difficult.  Cerebral  embolism  comes  on  very  sud- 
denly and  the  period  of  unconsciousness  usually  is  short;  with 
the  attack  also  we  observe  the  associated  heart  lesion.  Cere- 
bral thrombosis  usually  comes  on  slowly  with  prodromal 
symptoms,  such  as  vertigo,  paresthesias,  and  headache ;  it 
may,  however,  develop  rapidly.  Unconsciousness  may  or  may 
not  be  present.  The  onset  of  a  cerebral  hemorrhage  usually 
is  sudden  with  profound  unconsciousness;  the  symptoms  may 
however,  supervene  very  gradually — so-called  ingravescent 
hemorrhage. 

In  all  of  these  conditions  the  lesion  usually  is  on  one  side 
of  the  brain ;  the  motor  areas  of  the  affected  side  are  interfered 
with,  and  a  paralysis  of  motion  occurs  upon  the  opposite  side 
of  the  body.  During  the  acute  stage  of  the  attack  the  pulse 
is  usually  slow  and  full,  the  blood-pressure  increased,  and  the 
breathing  stertorous. 


CEREBRAL   APOPLEXY.  661 

The  head  and  eyes  are  commonly  turned  away  from  the 
paralyzed  side  (conjugate  deviation).  The  pupils  are  irre- 
sponsive to  light,  and  may  be  contracted.  The  muscles  of  the 
limbs  are  relaxed,  those  on  the  paralyzed  side  more  than  those  ^ 
on  the  sound  side.  The  temperature  at  first  may  be  sub- 
normal, but  later  it  tends  to  rise  1  or  2  degrees  above  normal. 
Frequently  the  axillary  temperature  of  the  paralyzed  side  is  a 
degree  higher  than  that  of  the  sound  side. 

If  the  patient's  condition  grows  worse,  the  pulse,  at 
first  slow  and  full,  now  becomes  rapid,  the  unconsciousness 
deepens,  the  temperature  rises  rapidly,  and  the  respiration  as- 
sumes the  Cheyne-Stokes  type.  In  cases  with  a  favorable 
outcome  the  patient  becomes  conscious  after  a  few  hours  or 
possibly  a  day,  and  then  one  side  of  the  body,  including  the 
lower  half  of  the  face,  is  noted  to  be  frankly  paralyzed.  In 
right-handed  individuals,  if  the  lesion  be  on  the  left  side, 
aphasia  is  present. 

The  tendon  reflexes  of  the  paralyzed  side  are  diminished  or 
absent  at  first;  though  a  Babinski  sign  may  be  noted  ver}^ 
early.  Later,  i.e.,  within  about  a  fortnight,  the  tendon  reflexes 
become  exaggerated,  and  the  Babinski  sign  is  commonly  pro- 
nounced. 

TREATMENT. 

As  a  preventive,  persons  with  atheromatous  arteries,  who 
have  passed  middle  life,  should  avoid  overeating,  overdrink- 
ing, and  strenuous  physical  exercise.  The  prolonged  adminis- 
tration of  small  doses  of  the  iodids  seems  to  have  a  beneficial 
effect  upon  the  arteriosclerosis.  The  persistent  administration 
of  small  doses  of  thyroid  extract  is  similarly  of  value. 

In  the  treatment  of  the  attack,  after  an  apoplexy  has  oc- 
curred, the  patient  should  be  kept  quiet  in  bed,  with  the  head 
slightly  elevated.  He  should  be  turned  on  his  side  part  of  the 
time,  so  that  the  paralyzed  tongue  may  fall  forward.  If  the 
blood-pressure  is  high,  venesection  may  be  of  benefit.  Ordi- 
narily full  doses  of  aconite,  or,  better,  veratrum  viride,  will 
quiet  the  pulse.  An  ice-cap  may  be  applied  to  the  head,  and 
heat,  in  the  form  of  hot  bottles,  or  hot  mustard  cloths,  to  the 
feet.  If  the  bladder  is  distended,  the  patient  should  be  cathe- 
terized.     A  brisk  purgative,  such  as  Epsom  salts,  should  be 


662  DISEASES    OF   THE    NERVOUS    SYSTEM. 

administered  if  the  patient  is  able  to  swallow ;  if  not,  the 
bowels  should  be  moved  by  enemas. 

In  fatal  cases  the  coma  deepens,  the  breathing  becomes 
Cheyne-Stokes  in  type,  and  the  temperature  rises.  In  favor- 
able cases  the  coma  gradually  becomes  less  profound,  and  in 
due  course  of  time  consciousness  returns.  The  paralysis  of 
the  affected  side  is  now  more  plainly  evident.  If  anesthesia 
be  present,  it  indicates  implication  of  the  posterior  third  of 
the  posterior  limb  of  the  internal  capsule.  The  speech  may 
be  thick  and  indistinct;  if  the  paralysis  is  on  the  right  side, 
aphasia  is  very  likely  to  be  present.  After  three  or  four 
weeks,  some  power  returns  in  arm  and  leg.  The  leg  usually 
improves  more  rapidly  than  the  arm,  and  the  proximal  mus- 
cles more  than  the  distal.  The  reflexes  now  become  exag- 
gerated and  the  palsied  muscles  are  spastic.  In  this  stage  but 
slight  further  improvement  takes  place,  and  little  can  be  ac- 
complished by  treatment.  The  iodids  may  be  given  in  moder- 
ate doses.  Electricity  is  of  no  value.  Massage,  and  especially 
passive  movements  of  the  paralyzed  limbs,  may  aid  in  prevent- 
ing severe  contractures. 

Apoplexy  is  usually  followed  by  some  degree  of  mental 
impairment — sometimes  very  slight,  sometimes  pronounced — 
together  with  associated  emotional  disturbances  and  irrita- 
bility. Nerve  sedatives,  such  as  the  bromids,  used  occasion- 
ally, may  be  of  benefit. 

BRAIN    TUMOR. 

Brain  tumor  occurs  in  persons  of  all  ages,  and  males  appear 
to  be  more  subject  to  such  neoplasms  than  females.  The 
causes  are  as  obscure  as  that  of  a  tumor  in  other  parts  of  the 
body,  and  any  variety  may  occur  in  the  brain.  The  most  com- 
mon are  tuberculous  tumors,  sarcoma,  glioma,  gliosarcoma, 
cyst,  carcinoma,  and  gumma.  In  a  brain  in  which  a  tumor 
has  developed,  the  membranes  are  likely  to  be  tense  and  the 
convolutions  flattened  from  pressure.  The  convolutions  in 
the  region  of  the  growth  do  not  pulsate.  The  ventricles  are 
prone  to  become  distended  with  fluid,  and  the  brain-tissue  wet 
and  heavier  than  normal.  A  zone  of  softening  frequently  is 
found  about  the  tumor. 


BRAIN    TUMOR.  663 

The  symptoms  of  brain  tumor  may  be  grouped  as  general 
and  focal.  The  general  symptoms  consist  of  headache,  vomit- 
ing without  gastric  disturbance — so-called  projectile  vomiting 
— and  optic  neuritis  followed  by  optic  atrophy.  Vertigo  is 
not  infrequent.  Mental  changes,  either  slight,  or  marked,  may 
also  be  present. 

The  focal  symptoms  depend  upon  the  part  of  the  brain  in 
which  the  growth  occurs.  Thus,  in  tumors  of  the  motor  area, 
focal  or  localized  epileptiform  convulsions  may  occur;  or 
there  may  be  various  forms  of  aphasia  due  to  left-sided  lesions, 
or  characteristic  disturbances  of  the  visual  fields  due  to  in- 
vasion of  the  optic  pathways,  or  of  the  occipital  lobe.  In 
estimating  the  value  of  localizing  signs,  it  should  be  borne  in 
mind  that  late  in  the  history  of  a  patient,  focal  symptoms  due 
to  increased  intracranial  pressure  and  circulatory  disturbances, 
may  point  to  parts  of  the  brain  not  attacked  by  the  tumor. 

The  diagnosis  of  brain  tumor  depends,  of  course,  on  the 
presence  of  the  symptoms  just  considered,  and  in  detail  upon 
a  correct  application  of  the  facts  of  cerebral  localization. 

TREATMENT. 

If  the  tumor  produces  clearly  defined  focal  symptoms,  and 
if  it  is  so  situated  that  it  can  be  removed  without  too  great  a 
danger  from  hemorrhage,  and  from  trauma  to  the  brain,  the 
surgical  treatment  of  the  condition  is,  other  things  being 
equal,  satisfactory.  If  the  tumor  should  be  a  gumma,  which 
fact  may  be  strongly  suggested  by  the  history  of  the  case,  and 
by  the  blood  and  spinal  fluid  findings,  the  use  of  full  doses  of 
mercurials  and  the  iodids  may  be  followed  by  good  results. 
A  course  of  intravenous  injections  of  salvarsan  should  also  be 
instituted.  Unfortunately,  the  larger  number  of  brain  tumors 
are  not  specific  in  origin.  However,  most  cases  are  benefited 
by  the  iodids,  given  first  in  small  doses,  and  gradually  in- 
creased to  the  point  of  tolerance.  The  treatment  is,  however, 
onh^  palliative,  and  the  benefit  temporary,  for  as  the  tumor 
becomes  larger,  the  symptoms  again  become  more  pronounced. 

A  brain  tumor  may  grow  slowly,  and  localizing  symptoms 
may  be  absent,  or  at  most  illy  defined,  and  the  symptoms  in 
such  cases  must  be  treated  as  they  arise.  Optic  neuritis 
should  be  treated  by  the  relief  of  intracranial  pressure.     Lum- 


664  DISEASES    OF   THE    NERVOUS    SYSTEM. 

bar  puncture  guardedly  performed  may  be  of  value,  from  4 
to  6  mils  (1  to  1.6  fo)  of  spinal  fluid  being  withdrawn  at  in- 
tervals of  every  day,  or  every  other  day,  and  if  no  unfavorable 
symptoms  make  their  appearance,  the  amount  withdrawn 
should  be  progressively  increased.  Marked  subsidence  of  the 
swelling  of  the  optic  disc  may  follow  this  expedient.  Sudden 
and  large  withdrawal  of  spinal  fluid  may  be  followed  by  a  fatal 
result.  The  operation  of  cerebral  decompression  is  more 
radical,  and  gives  prompt  relief  to  both  the  headache,  and 
swelling  of  the  optic  nerve.  Right  subtemporal  decompres- 
sion is  the  operation  most  frequently  performed.  Subtentorial 
decompression  is  adopted,  when  the  symptoms  suggest  the 
possibility  of  the  tumor  of  the  posterior  cranial  fossa.  Un- 
fortunately, many  cases  come  to  the  hospital,  or  to  the  hands 
of  the  neurologist  so  late  that  decompression  fails  to  preserve 
the  vision  of  the  patient.  When  optic  atrophy  has  been  estab- 
lished, decompression  has  little  to  ofifer  save  the  relief  of  pain. 
However,  in  cases  in  which  the  tumor  can  be  localized  and 
the  skull  opened  over  the  tumor,  even  though  the  latter  proves 
to  be  inoperable,  the  intracranial  pressure  and  headache  are 
relieved  for  a  time. 

Headache,  vomiting,  and  vertigo  may  be  so  severe  as  to 
demand  symptomatic  treatment,  and  here  the  bromids,  the 
coal-tar  products,  and  even  morphin,  and  scopolamin  may  be 
employed.  Severe  and  frequent  convulsions  may  be  con- 
trolled by  the  bromids  and  chloral. 

DISEASES  OF  THE  SPINAL  CORD  AND 
ITS  MEMBRANES. 

Inflammatory  diseases  of  the  spinal  meninges  usually  are 
associated  with  similar  disease  processes  in  the  meninges  of 
the  brain.  An  exception  to  this  is  hypertrophic  cervical 
pachymeningitis,  which  occurs  as  a  distinct  affection. 

Hypertrophic  Cervical  Pachymeningitis.  Trauma,  tuber- 
culosis, and  especially  syphilis,  appear  to  be  prominent  fac- 
tors of  this  afi^ection,  while  other  potential  causes,  such  as 
rheumatism  and  alcohol,  deserve  less  credit. 

The  early  symptoms  consist  of  pains  in  the  back  of  the 
neck,  sometitnes  in  the  occipital  region,   frequently  between 


SPINAL   CORD   AND    MEMBRANES.  665 

the  shoulders;  a  feeling  of  tension,  and  at  times  of  stiffness; 
sensitiveness  of  the  cervical  spinous  processes  to  percussion; 
and  various  pains,  and  paresthesias,  due  to  implication  of  the 
roots.  Inasmuch  as  the  lower  cervical  region  commonly  is 
most  affected,  pains  are  quite  frequent  in  the  course  of  the 
median  and  ulnar  nerves.  Wasting  of  the  muscles  supplied 
by  these  nerves,  the  flexor  group  of  the  forearm,  and  the  small 
muscles  of  the  hand,  subsequently  develops,  and,  finally,  symp- 
toms of  compression  of  the  cervical  cord  appear.  Spastic 
paralysis  of  the  legs,  anesthesia,  and  sphincter  disturb- 
ances may  be  noted.  The  course  of  the  disease  is  slowly 
progressive,  the  palsies,  muscular  atrophies,  and  sensory 
losses  gradually  increasing.  Sometimes  arrest  of  progress  is 
observed. 

A  marked  hypertrophy,  or  thickening  of  the  dura  mater  is 
present,  and  as  this  hypertrophy  takes  place,  the  growth  im- 
plicates, on  the  one  hand  the  periosteum,  and,  on  the  other, 
the  pia-arachnoid,  the  nerve  roots,  and  the  cord ;  and  the  newly 
formed  tissue  binds  membranes,  roots,  and  cord  into  a  single 
mass. 

If  the  disease  is  due  to  syphilis,  vigorous  antiluetic  treat- 
ment should  be  instituted.  Otherwise  the  treatment  must  be 
symptomatic.  In  rare  cases,  surgery  may  be  justified,  free 
laminectomy  being  the  operation  of  choice.  If  indicated,  it 
should  be  done  early,  and  before  the  cord  and  nerve-roots  have 
been  too  greatly  damaged. 

Spinal  leptomeningitis  usually  is  part  and  parcel  of  a  gen- 
eral cerebrospinal  meningitis.  In  rare  cases  it  occurs  as  a 
local  process  within  the  spinal  canal,  due  to  malignant,  tuber- 
cular, syphilitic,  or  other  infection.  The  epidemic  variety  may 
be  limited  to,  or  most  pronounced  in,  the  spinal  meninges.  It 
may  occur  as  a  sequel  to,  or  a  complication  of,  the  infectious 
diseases,  and  in  this  event  usually  is  associated  with  myelitis. 

Dilatation  of  the  blood-vessels  of  the  meninges  appears  to 
be  present  in  the  beginning-  of  the  disease,  and  is  followed  by 
a  serous,  or  seropurulent  exudate.  The  membranes  become 
the  seat  of  inflammatory  infiltration  and  deposit,  and  the 
spinal  fluid  becomes  turbid  from  the  presence  of  formed  ele- 
ments. AMienever  practicable,  it  should  be  submitted  to 
microscopic  and  b^gteriologic  examination, 


666  DISEASES    OF   THE   NERVOUS    SYSTEM. 

The  onset  of  the  symptoms  may  be  marked  by  a  chill  and 
fever,  pain  and  rigidity  of  the  muscles  of  the  back  and  neck, 
shooting  pains,  and  general  hyperesthesia,  retraction  of  the 
abdomen,  spasms  of  the  muscles  of  the  arms  and  legs,  ex- 
aggerated tendon  reflexes,  and  Kernig's  sign,  i.e.,  if  the  thigh 
be  flexed  at  right  angles  to  the  trunk,  the  lower  leg  cannot  be 
extended  owing  to  spasm  of  the  flexors.  Later  there  may  be 
palsies,  loss  of  control  of  the  bladder,  and  various  sensory 
losses. 

The  prognosis  is  always  bad  in  tubercular  cases;  those 
following  acute  infectious  diseases  at  times  terminate  in  re- 
covery, although  permanent  damage  to  nerve-roots  or  cord 
may  result. 

The  treatment  is  that  of  the  underlying  general  infection, 
such  as  syphilis,  or  tuberculosis,  and  the  disease  in  question 
should  be  managed  from  its  particular  standpoint.  Rest  in 
bed  with  an  ice-bag  to  the  spine  is  indicated.  Counterirrita- 
tion  over  the  spine  may  be  used  later.  Lumbar  puncture  with 
the  withdrawal  of  cerebrospinal  fluid  is  reported  of  benefit  in 
the  treatment  of  various  forms  of  meningeal  infection.  Spinal 
drainage,  of  great  importance  in  diagnosis,  relieves  intraspinal 
pressure  for  a  time,  and  is,  as  a  rule,  a  safe  procedure. 

In  the  treatment  of  the  epidemic  form,  i.e.,  of  cerebrospinal 
meningitis,  a  great  advance  has  been  made  in  the  introduction 
of  Flexner's  serum.     (See  Cerebral  Leptomeningitis,  p.  654.) 

DISEASES    OF    THE    SPINAL    CORD 

Diseases  of  the  spinal  cord  are  conveniently  divided  into 
two  classes ;  those  affecting  chiefly  certain  tracts  or  systems 
of  neurons  in  the  cord  (System  Diseases),  and  those  character- 
ized by  dififuse  lesions  throughout  the  cord  (Diffuse  Diseases). 
In  the  first  group  the  nerve  cells  and  tracts  are  primarily  af- 
fected; and  in  the  second  group  the  lesion  usually  is  one  pri- 
marily of  the  blood-vessels,  and  connective  tissue  elements. 
This  division  is  open  to  some  objection,  as  in  given  instances, 
e.g.,  tabes,  the  lesion  is  not  confined  to  the  nerve  elements 
alone,  but  also  affects  the  membranes  and  the  blood-vessels. 

The  most  important  system  cord  disease  affecting  the  sen- 
sory tract  is  tabes  dorsalis,  the  treatment  of  which  will  be 


HEREDITARY    SPASTIC    PARAPLEGIA.  667 

considered  in  the  section  on  the  treatment  of  syphilis  of  the 
nervous  system.     (See  p.  689.) 

A  consideration  of  the  motor  tract  is  essential  to  an  under- 
standing of  the  various  motor  system  diseases  of  the  cord. 
The  upper  motor  segment  or  neuron  includes  that  part  w^hich 
begins  on  the  cells  of  the  motor  cortex.  The  individual  axons 
pass,  as  axis  cylinders,  downward  through  the  centrum  ovale, 
internal  capsule,  crus,  pons,  and  cord,  and  end — through  an 
intermediate  short  neuron — near  the  large  multipolar  cells  in 
the  anterior  horn  of  the  gra}^  matter  of  the  cord.  They  are 
in  physiologic  continuity  with  these  multipolar  cells.  The 
lower  motor  segment  or  neuron  begins  in  the  multipolar  cells 
in  the  anterior  horns,  and  continues  through  the  anterior  roots 
as  axis  cylinders  through  the  nerve  trunks  to  the  muscles. 
The  upper  neuron  may  be  diseased  at  any  point  in  its  course. 

The  symptoms  consist  of  paralysis  and  spasticity  of  mus- 
cles, exaggerated  tendon  reflexes,  and  the  Babinski  sig'n.  The 
latter  consists,  the  reader  will  remember,  of  an  extension  of  the 
toes,  especially  the  great  toe,  upon  irritation  of  the  sole  of  the 
foot.  There  is  no  muscular  wasting,  and  no  change  in  the 
reaction  of  the  muscle  to  the  electric  current.  If  the  lower 
motor  neuron  be  afit'ected,  the  symptoms  consist  of  paralysis, 
flaccidity,  wasting  of  muscles,  diminished  or  lost  refle>;es,  and 
a  change  in  the  reaction  of  the  muscle  to  the  galvanic  current, 
ther  so-called  reaction  of  degeneration.  In  this  the  normal 
sequence  of  response  is  changed  to  the  opening  and  closing  of 
the  poles,  so  that  in  the  fully  developed  case  the  anodal  closure 
contraction  is  finally  greater  than  the  cathodal  closure  con- 
traction. Various  intermediate  stages  are,  of  course,  to  be 
noted.  Lesions  of  both  the  upper  and  the  lower  sj'stems  pre- 
sent a  combination  of  muscular  rigidity  with  muscular 
atrophy. 

DISEASES  AFFECTING  THE  UPPER 
MOTOR  NEURON. 

HEREDITARY  SPASTIC  PARAPLEGIA. 

This  is  a  rare  afifection,  described  by  Striimpell.  which 
appears  in  a  number  of  members  of  a  family  in  the  same  or 
different  generations.     Syphilis  appears  to  play  a  part  in  the 


DISEASES    OF   THE   NERVOUS    SYSTEM. 

etiology  in  at  least  some  of  the  cases.  The  clinical  picture  may 
assume  either  a  spinal  or  cerebral  type.  The  spinal  type  ap- 
pears to  depend  on  degeneration,  apparently  abiogenetic  in 
character,  of  the  motor  tracts  in  the  cord. 

The  symptoms  are  those  of  lesion  of  the  upper  motor 
neuron,  without  cerebral  manifestations,  such  as  mental  arrest 
and  epilepsy.  The  diagnosis  depends  on  the  occurrence  of  the 
disease  in  other  members  of  the  family,  its  gradual  develop- 
ment, and  the  absence  of  initial  convulsions  and  other  cere- 
bral symptoms. 

The  prognosis  is,  of  course,  unfavorable  as  to  cure. 

The  treatment  is  purely  symptomatic.  If  syphilis  is  shown 
to  be  the  cause,  some  result  may  possibly  be  obtained  by  the 
specific  treatment  of  this  infection. 

SPASTIC    PARALYSIS    OF    INFANTS    AND 
CHILDREN. 

This  condition  may  present  itself  as  a  hemiplegia,  a 
diplegia,  or  a  paraplegia. 

The  condition  is  due  to  disease  or  injury  affecting  the 
motor  areas  of  the  brain.  The  cause  of  the  defect  may  be 
traced  to  prenatal  or  intrauterine  conditions,  to  lesions  inci- 
dent to  birth,  and  to  those  occurring  after  birth.  Hereditary 
syphilis,  alcoholism,  uterine  trauma,  and,  possibly,  psychic 
disturbance  of  the  mother,  may  produce  a  cerebral  defect  in 
the  child.  Premature  birth,  with  an  associated  lack  of  develop- 
ment of  the  pyramidal  tracts,  and  prolonged,  difficult  births 
are  of  etiologic  importance.  As  regards  the  latter,  it  should 
be  borne  in  mind  that  the  use  of  forceps  correctly  applied  is 
of  less  danger  than  the  severe  and  persistent  pressure  such 
as  takes  place,  for  instance,  when  the  head  ceases  to  recede 
between  the  pains  of  a  difficult  and  prolonged  labor.  Cerebral 
palsy  may  also  follow  the  infectious  fevers.  Hemorrhage, 
thrombosis,  embolism,  or  localized  encephalitis  also  may  be 
the  causal  factors.  Trauma  to  the  head  is  a  rare  cause.  Hemi- 
plegia usually  is  not  congenital.  Diplegia  or  paraplegia,  often 
spoken  of  as  Little's  disease,  are,  however,  commonly  con- 
genital. Many  of  these  palsies  are  apparently  abiogenetic  in 
origin,  the  motor  area  failing  of  full  development. 


PRIMARY   LATERAL   SCLEROSIS.  669 

The  symptoms  are  those  of  hemiplegia  or  double  hemi- 
plegia, with  spasticity  and  contractures.  In  diplegia,  if  the 
patient  be  able  to  walk,  the  gait  is  frequently  that  of  a  "cross- 
legged  progression." 

Inasmuch  as  most  of  these  patients  come  under  observa- 
tion after  the  spastic  condition  of  the  muscles  has  developed, 
the  treatment  usually  resolves  itself  into  methods  of  ameliorat- 
ing the  spasticity  and  the  deformities  caused  thereby.  The 
patient  should  not  be  allowed  to  walk  early,  in  order  that 
defective  nerve  tracts  may  be  spared.  Warm  baths,  gentle 
massage,  and  proper  exercise  counteract  the  tendency  to  con- 
tracture. Drugs  have  no  marked  influence  upon  the  disease, 
except,  possibly,  in  those  cases  due  to  syphilis. 

In  cases  presenting  marked  contracture,  benefit  may  be 
obtained  by  tenotomy.  The  dorsal  nerve  roots  also  may  be  cut 
to  overcome  great  spasticity,  as  advocated  by  Foerster,  and 
also  by  Spiller  and  Frazier.  The  cerebral  hemorrhage  oc- 
curring in  the  newly  born,  and  so  often  causal  to  these  condi- 
tions, frequently  may  be  relieved  by  operation,  as  done  by 
Gushing.  The  epilepsy  which  so  frequently  accompanies 
these  gross  cerebral  defects  is  to  be  treated  on  the  same  gen- 
eral principles  as  idiopathic  epilepsy.  The  mental  condition 
may  be  improved  by  special  methods  of  training,  as  carried  out 
in  institutions  for  feeble-minded  children. 

PRIMARY    LATERAL    SCLEROSIS. 

This  condition  is  one  of  the  infrequent  forms  of  organic 
nervous  disease.  It  has  rarely  been  confirmed  by  autopsy,  al- 
though a  very  few  cases  have  been  reported  in  which  no  lesion 
was  found  except  degeneration  of  the  lateral  tracts. 

The  etiology  is  obscure.  Some  cases  seem  to  follow 
syphilis.  In  some  there  is  a  history  of  general  debility,  infec- 
tious diseases,  traumatism,  and  exposure  to  cold  and  wet. 
Most  cases  arise  between  20  and  40  years  of  age. 

The  symptoms,  relating  to  a  lesion  of  the  upper  motor  neu- 
ron, develop  gradually,  and  may  exist  for  a  number  of  years 
before  the  weakness  becomes  extreme.  In  advanced  cases 
the  patient  may,  as  in  infantile  diplegia,  walk  with  one  leg- 
crossed  over  the  other. 


670  DISEASES    OF    THE    NERVOUS    SYSTEM. 

The  diagnosis  rests  upon  the  history  and  symptomatology. 
There  are  no  sensory  changes,  no  trophic  changes,  no  implica- 
tion of  the  sphincters,  and  no  ataxia. 

The  treatment  is  unsatisfactory ;  drugs  such  as  mercury  and 
iodids,  silver  and  arsenic  may  be  tried,  but  usually  fail  of 
effect.  Strychnin  should  not  be  given.  Rest,  warm  baths  and 
massage  may  be  of  service  to  relieve  the  spasticity. 

DISEASES  OF  THE  LOWER  MOTOR 
NEURON. 

ACUTE    ANTERIOR    POLIOMYELITIS. 

This  affection,  strictly  speaking,  is  not  a  neuron  disease, 
but  it  is  classed  as  such,  since  its  most  striking  symptoms  are 
shown  by  the  lesions  of  the  lower  motor  neuron.  Acute 
anterior  poliomyelitis  is  an  acute  infection,  affecting  the  cere- 
brospinal axis  as  a  whole.     (C/.  p.  111.) 

The  exact  cause  of  the  disease  has  not  yet  been  conclusively 
shown.  The  virus  is  known  to  filter  through  porcelain  and 
asbestos  filters,  and  to  be  highly  resistant  to  various  destruc- 
tive agencies.  Apparently  it  is  not  affected  by  gastric  and  in- 
testinal juices,  and  can  resist  for  three  days  without  injury, 
a  0.5  per  cent,  solution  of  carbolic  acid.  It  is  readily  destroyed 
by  heat  at  50°  C.  (122°  F.)  for  one-half  hour.  It  appears  that 
the  virus  gains  entrance  to  the  respiratory  tract,  infects  the 
lymphatics  of  the  upper  air  passages,  and  subsequently  in- 
vades the  meninges  and  the  substance  of  the  brain  and  cord. 

In  the  early  stage  there  is  a  hyperemia  of  the  cord  and 
meninges,  and  the  blood-vessels  of  both  brain  and  cord  are 
dilated.  There  is  edema  of  the  cerebrospinal  axis,  with  but 
little  if  any  increase  of  the  cerebrospinal  fluid,  which  at  first, 
as  a  rule,  is  clear,  but  contains  a  large  number  of  polynuclear 
cells.  In  a  few  days  the  mononuclear  cells,  lymphocytes, 
predominate.  The  perivascular  lymph  spaces  of  the  blood- 
vessels of  the  meninges  are  filled  with  an  exudate  of  small 
mononuclear  cells — an  acute  interstitial  meningitis.  Since  the 
blood-supply  of  the  cord  is  derived  from  the  vessels  of  the 
meninges,  the  perivascular  infiltration  extends  into  the  sub- 
stance  of   the   cord    as   the   disease   process    advances.     This 


ACUTE   ANTERIOR   POLIOMYELITIS.  671 

round-celled  infiltration  becomes  so  dense  in  areas  as  to  ob- 
struct the  blood-supply  of  the  nerve  cells.  Minute  hemor- 
rhages also  may  be  present  in  both  the  gray  and  the  white 
matter  of  the  cord.  The  lack  of  nutrition  of  the  nerve  cells 
soon  results  in  their  atrophy  and  death.  It  is  possible,  ot 
course,  that  the  toxin  of  the  infection  may  have  an  especially 
destructive  effect  upon  the  nerve  cells. 

The  symptoms  at  the  onset  of  the  disease  vary  in  different 
patients.  A  child  in  previous  good  health  may  be  put  to  bed, 
apparently  well,  to  awake  in  the  morning  paralyzed  in  one  or 
more  extremities,  while  another  child,  suffering  from  some 
acute  disease,  acquires  the  anterior  poliomyelitis  as  a  com- 
plication. Still  another  may  be  ill  for  a  numl^er  of  days  before 
any  signs  of  palsy  are  seen,  and  it  is  thought  that,  during 
epidemics  especially,  numbers  of  children  are  attacked  and 
recover  without  reaching  the  stage  of  paralysis.  The  disease 
comes  on  with  fever  varying  from  100°  to  103°  F.  {37.7°  to 
39.4°  C),  often  accompanied  by  vomiting,  and  at  times  by 
diarrhea. 

The  child  complains  of  headache,  or  if  too  young  to  state 
his  complaint,  will  show  signs  of  hebetude  and  irritability. 
Nasopharyngeal  symptoms,  such  as  sneezing  and  free  dis- 
charge of  mucus,  may  be  present.  Because  of  irritation  of  the 
spinal  roots,  the  pain  is  referred  to  the  joints  or  extremities; 
this  pain  frequently  precedes  the  onset  of  paralysis.  The 
paralysis  comes  on  quickly,  and,  as  a  rule,  soon  reaches  its 
maximum.  It  may  present  itself  as  a  monoplegia,  hemiplegia, 
paraplegia,  or  all  four  extremities  may  be  involved.  Most  fre- 
quently it  is  one  leg  which  is  especially  affected;  less  fre- 
quently both.  All  the  symptoms  of  a  lower  motor  neuron 
lesion  are  present;  rapidly  wasting  muscles  showing  the  re- 
action of  degeneration,  minus  or  absent  reflexes,  flaccid  paral- 
ysis, and  cold,  livid,  clammy  skin.  Cranial  nerve  palsies  are 
present  in  cases  in  which  the  disease  implicates  the  medulla. 

The  prognosis  as  to  life  is  good  in  the  average  case;  how- 
ever, cases  arising  during  epidemics,  at  which  times  the  viru- 
lence of  the  infection  appears  to  be  greatly  increased,  and  the 
meninges  and  brain  severely  damaged,  give  a  relativelv  un- 
favorable prognosis  as  to  life.  Notwithstanding  this,  a  spon- 
taneous and  almost  complete  recovery  may  occur. 


672  DISEASES    OF   THE   NERVOUS    SYSTEM. 

The  average  case  of  palsy  improves  rapidly  for  the  farst 
few  weeks,  and  some  children  recover  almost  entirely  during 
this  period.  Subsequently,  however,  further  progress  is  slow, 
but  the  improvement  continues  for  several  years.  The  prog- 
nosis as  to  recovery  from  the  palsy  is  not  good;  even  in  the 
most  favorable  cases  some  traces  of  the  disease  generally  will 
be  found  to  persist  as  a  relic  of  the  attack. 

TREATMENT. 

Most  observers  agree  that  the  disease  is  contagious.  In 
any  event  a  strict  quarantine  should  be  maintained  for  a  num- 
ber of  weeks.  The  premises  must  be  made  sanitary.  As  the 
exact  way  in  which  the  virus  is  transmitted  is  not  known,  all 
possible  carriers  should  be  borne  in  mind.  Insects  of  all 
kinds,  especially  flies,  should  be  screened  from  houses,  and 
food,  such  as  water,  milk,  and  uncooked  vegetables,  be  kept,  if 
possible,  free  from  contamination.  That  dirty  and  dusty 
streets  and  alleys  should  receive  attention  need  hardly  be 
mentioned. 

As  a  prophylactic  measure,  care  should  be  taken  to  see 
that  the  child's  mucus  membranes,  both  of  the  nasopharyngeal 
and  gastrointestinal  tracts,  are  in  the  best  possible  condition. 

During  the  acute  febrile  stage,  the  child  should  rest  in  bed, 
and,  because  of  the  pain,  be  handled  as  little  as  possible.  If 
there  is  much  fever,  the  ice-cap  may  be  applied.  Bromids 
may  be  sufficient  to  quiet  the  patient,  although  occasionally 
it  may  be  necessary  to  give  the  coal-tar  products,  or  even 
opiates.  The  diet  should  be  such  as  will  easily  digest,  and  the 
bowels  should  be  kept  free.  A  number  of  acute  cases  have 
been  treated  with  immune  serum,  that  is,  with  the  serum  of 
the  blood  of  children  who  have  recovered  from  the  disease. 
Favorable  results  are  thought  to  have  been  obtained  by  this 
method,  although  a  sufficiently  large  number  of  cases  have 
not  yet  been  treated  to  establish  with  certainty  its  advantages. 

For  the  paralysis  the  patient  should  have  absolute  rest  for 
three  months.  The  paralyzed  limbs  are  best  put  up  in  plaster- 
of-Paris  splints.  If  it  be  the  leg  that  is  palsied,  the  limb 
should  be  flexed  slightly  at  the  knee  and  the  foot  fixed  at  a 
right  angle.  If  the  arm  be  affected,  it  should  be  slightly  flexed 
at  the  elbow,  the  hand  hyperextended,  and  the  fingers  and 


ACUTE    BULBAR   PARALYSIS.  673 

thumb  put  up  in  full  extension.  If  the  shoulder  muscles  are 
paralyzed,  the  arm  should  be  elevated  and  abducted  at  a  right 
ang-le  to  the  body.  If  the  muscles  of  the  back  are  affected,  the 
patient  should  have  a  plaster  dressing  molded  to  the  back, 
and  in  this  the  subject  should  lie  after  it  has  been  padded  with 
cotton.  In  other  w^ords,  complete  rest  promotes  absorption 
and  diminishes  pressure.  The  principle  is  to  relieve  the  weak 
and  atrophied  muscles  of  all  strain.  The  nerve  cells  also 
have  a  better  opportunity  to  recover,  if  recovery  be  possible. 
Light  massage  is  beneficial  after  the  acute  stage  has  passed. 
Muscle  training  is  of  value,  but  must  not  be  overdone  with 
weak  muscles.  Braces  should  be  applied  to  counteract  a 
stronger  group  of  opposing  muscles;  they  should  not,  how- 
ever, interfere  with  muscular  development.  If  the  patient  can 
walk  without  the  development  of  a  deformity,  no  brace  is 
needed.  If  there  be  a  palsy  of  the  muscles  of  the  back,  limited 
to  one  side,  a  deformity  of  the  spine  must  be  carefully  guarded 
against,  usually  by  the  application  of  a  corset  with  steel  sup- 
porting bars. 

Exercise  in  a  bathtub  filled  with  water  may  be  of  use,  for 
by  this  expedient  the  partly  paralyzed  limbs  can  be  moved 
about  in  the  water  more  readily.  Heat  and  vibration  over  the 
spine,  applied  late,  may  have  some  stimulating  effect  upon  the 
diseased  cord.  Electricity  has  little  value  except  to  exercise 
the  muscles.  Its  use  in  this  way,  however,  should  not  be  over- 
done. 

The  treatment  should  be  continued  over  a  very  long  time. 
Not  infrequently  patients  who  are  carried  into  the  clinic  with 
both  legs  paralyzed  may,  after  treatment  for  a  year  or  more, 
be  able  to  walk  with  the  aid  of  braces. 

ACUTE    BULBAR    PARALYSIS. 

An  acute  bulbar  palsy  may  be  due  to  an  infection,  in  which 
case  it  is  analogous  to  acute  anterior  poliomyelitis ;  indeed,  it 
is  not  improbable  that  in  given  instances  the  virus  is  the  same. 
If  the  anterior  group  of  motor  nuclei  are  aft"ected,  more  espe- 
cially the  oculomotor  group,  the  disease  is  known  as  polio- 
encephalitis superior.  If  the  nuclei  from  the  seventh  to  the 
twelfth  cranial  nerves  are  the  seat  of  the  lesion,  it  is  spoken 

43 


674  DISEASES   OF   THE   NERVOUS    SYSTEM. 

of  as  polioencephalitis  inferior.  The  symptoms  may  also  be 
due  to  hemorrhage  or  to  thrombosis  of  the  vertebral  arteries, 
of  the  basilar,  or  of  their  branches.  Embolism  and  hemorrhage 
are  uncommon  causes. 

The  symptoms  may  come  on  rapidly.  The  muscles  of  the 
lips,  tongue,  pharynx,  palate,  and  larynx  become  paralyzed. 
Difficulty  in  swallowing  and  speaking  is  present,  and  the 
patient  may  die  from  the  effects  of  cardiac  and  respiratory 
complications.  If  the  condition  be  that  of  a  superior  polioen- 
cephalitis, the  prognosis  as  regards  life  is  better.  If  the  symp- 
toms are  due  to  a  vascular  lesion,  they  arise  with  apoplecti- 
form suddenness,  and  are  likely  to  be  fatal. 

PROGRESSIVE    MUSCULAR    ATROPHY. 

Progressive  muscular  atrophy  of  spinal  origin  is  charac- 
terized by  a  slow,  progressive  wasting,  usually  beginning  in 
the  small  muscles  of  the  hand,  or,  it  may  be,  in  the  muscles  of 
the  shoulder  girdle. 

The  disease  usually  occurs  during  adult  life,  and  no 
specific  cause  is  known.  Heredity  is  not  a  factor.  More  males 
are  attacked  than  females.  Overwork,  exposure',  spinal  con- 
cussion, syphilis,  and  lead  poisoning  are  thought  to  be  factors 
in  various  cases.  Not  infrequently  cases  are  met  with  giving 
a  positive  Wassermann,  increased  lymphocytes,  and  globulin 
in  the  spinal  fluid. 

The  anterior  horn  cells  atrophy  and  disappear,  with  a  con- 
sequent atrophy  of  the  muscles  supplied  by  these  cells.  The 
skin  is  not  affected. 

The  symptoms  of  the  disease  develop  insidiously.  Atrophy 
may  exist  in  the  muscle  for  some  time  before  the  patient 
notices  weakness.  It  usually  begins  in  the  small  muscles  of 
the  hand,  and  in  years  of  time  extends  to  the  muscles  of  the 
arms,  shoulders,  neck,  and  trunk.  The  patient  may  complain 
of  some  aching  and  paresthesia  of  the  hands.  In  a  small  num- 
ber of  cases  the  atrophy  begins  in  the  lower  extremities.  The 
reflexes,  normal  elsewhere,  are  diminished  in  the  paralyzed 
muscles.  Fibrillary  tremors  are  present  in  the  atrophied 
muscles,  and  there  is  a  quantitative  change  in  their  reaction  to 
electricity.     In  advanced  cases  complete  RD  may  develop. 


CHRONIC   PROGRESSIVE   BULBAR   PALSY.  675 

The  diagnosis  rests  upon  the  history  and  local  signs  of 
atrophy,  together  with  the  absence  of  signs  pointing  to  im- 
plication of  other  parts  of  the  spinal  cord  or  of  the  nerve 
trunks. 

Chronic  anterior  poliomyelitis  greatly  resembles  this  dis- 
ease, and  from  the  standpoint  of  prognosis  and  treatment  may 
be  considered  with  it.  Chronic  anterior  poliomyelitis  comes 
on  more  quickly  than  progressive  muscular  atrophy,  as  a  rule 
affects  a  large  group  of  muscles  early,  and  the  paralysis  is 
noted  before  the  atrophy  develops. 

If  syphilis  is  shown  to  be  the  cause,  intraspinal  specific 
methods  of  treatment  are  indicated.  (See  p.  689.)  In  other 
cases  general  measures  must  be  employed.  Rest,  moderate 
exercise,  and  full  feeding  are  indicated.  Properly  applied 
electricity  and  massage  are  useful.  Full  doses  of  strychnin 
are  believed  to  be  of  benefit  in  retarding  the  development  of 
the  disease. 

CHRONIC    PROGRESSIVE    BULBAR    PALSY. 

This  disease  appears  to  be  analogous  to  progressive  spinal 
muscular  atrophy.  The  degenerative  and  atrophic  process  at- 
tacks the  nerve  nuclei  in  the  medulla. 

The  disease  comes  on  in  adult  life,  and  is  known  as  glos- 
solabiolaryngeal  paralysis.  The  muscles  of  the  lips,  tongue, 
palate,  pharynx,  and  larynx  gradually  atrophy,  and  difficulty  in 
phonation  and  deglutition  becomes  pronounced.  The  outlook 
is  unfavorable,  and  death  ensues  in  a  few  days. 

The  treatment  is  purely  symptomatic,  and  the  measures 
adopted  in  progressive  muscular  atrophy  of  spinal  origin  are 
indicated  in  this  affection.  Care  in  giving  food  and  drink  to 
the  patient  is  necessary  to  avoid  an  insufflation  pneumonia. 

Pseudobulbar  paralysis  presents  symptoms  resembling 
chronic  bulbar  paralysis,  with  the  exception  that  muscular 
atrophy  is  not  present.  It  is  due  to  bilateral  lesions  above  the 
lower  motor  neuron,  e.g.,  in  the  lenticular  nuclei  or  the  internal 
capsules.  In  this  lesion  the  outlook  is  unfavorable,  and  the 
treatment  purely  symptomatic. 


676  DISEASES   OF   THE   NERVOUS    SYSTEM. 

AMYOTROPHIC    LATERAL    SCLEROSIS. 

This  affection  is  the  most  typical  example  of  lesion  of  both 
upper  and  lower  motor  neurons.  The  disease  is  more  com- 
mon in  males,  and  between  the  ages  of  30  and  50.  Heredity 
plays  no  part.  Poisons,  such  as  lead,  and  infections,  such  as 
syphilis,  are  possible  etiologic  factors,  but  no  definite  cause 
is  known. 

There  is  a  slow  degeneration  of  the  anterior  horn  cells, 
usually  beginning  in  the  cervical  region,  as  in  chronic  pro- 
gressive muscular  atrophy  of  spinal  origin.  Associated  with 
this  is  a  degeneration  of  the  pyramidal  tracts.  In  other  words, 
the  morbid  anatomy  of  this  disease  presents  a  combination  of 
the  lesions  of  progressive  muscular  atrophy  with  primary 
lateral  sclerosis. 

The  symptoms  are  a  combination  of  the  symptoms  of  dis- 
ease of  both  the  upper  and  the  lower  motor  neuron — wasting 
of  the  small  muscles  of  the  .hands  and  arms,  with  spasticity  of 
muscles,  and  increased  reflexes  in  the  lower  extremities.  The 
course  of  the  disease  is  slow%  but  progressive. 

No  treatment  is  known  to  check  the  disease.  The  little  that 
may  be  done  in  the  way  of  treatment  has  been  outlined  in  the 
sections  on  lateral  sclerosis  and  progressive  muscular  atrophy. 
(See  pp.  669  and  674.) 

COMBINED  SYSTEM  DISEASES 

The  essential  feature  of  this  type  of  disease  is  a  combina- 
tion of  symptoms  due  to  disease  of  both  the  posterior  and  the 
lateral  columns.    The  anterior  horns  are  not  implicated. 

ATAXIC    PARAPLEGIA. 

The  terms  combined  sclerosis  and  posterolateral  sclerosis 
are  used  as  synonyms  for  this  disease,  for  which  no  specific 
cause  is  known.  It  is  a  disease  of  adult  life,  and  more  common 
in  males  than  in  females.  Syphilis  may  be  a  cause,  and  some 
cases  develop  during  the  course  of  pernicious  anemia. 

Both  posterior  and  lateral  columns  of  the  cord  become 
sclerotic,  and  the  process  is  often  diffused  into  the  mixed  zones 


HEREDITARY    ATAXIA.  677 

of  the  lateral  columns.  The  direct  anterior  tracts  also  are 
attacked  in  nearly  all  cases. 

The  symptoms  of  the  disease  develop  slowly,  as  a  rule. 
Ataxia,  combined  with  weakness  and  stiffness  of  muscles,  is 
noted,  but  sensation  usually  is  not  impaired.  Lightning-  pains 
are  absent,  but  dull  pain  in  sacral  reg"ion  may  be  complained 
of.  Visceral  crises  are  unknown.  The  knee-jerks  are  greatly 
increased ;  ankle  clonus  and  the  Babinski  sign  are  present. 
Sexual  power  is  lost  early,  and  the  sphincters  are  often  im- 
paired.    Eye  symptoms  are  not  present. 

The  disease  lasts  for  many  years,  and  recovery  never 
ensues. 

If  the  spinal  fluid  presents  the  evidence  of  syphilis,  intra- 
spinal methods  of  treatment  should  be  employed  (q.v.,  p.  689). 
Otherwise,  good  hygienic  surroundings,  warm  climate,  and 
warm  baths  are  indicated  for  the  spasticity.  Electricity  and 
strychnin  should  not-be  used.  Arsenic  may  be  given.  Courses 
of  the  bromids  may  be  useful  at  times. 

HEREDITARY    ATAXIA. 

This  affection  may  be  classed  under  two  types :  Fried- 
reich's disease  and  hereditary  cerebellar  ataxia. 

The  lesions  in  Friedreich's  disease  are  of  the  combined 
spinal-cord  type,  the  chang"es  in  the  cord  consisting  mainly  of 
a  sclerosis  of  the  posterior  and  lateral  columns.  Atrophy  of  the 
cerebellum  has  been  found  in  some  cases  of  cerebellar  ataxia. 
Friedreich's  disease  develops  at  or  before  puberty,  and  is  a 
family  disease.  The  cerebellar  form  is  prone  to  develop  at 
puberty  or  after. 

Both  forms  of  the  disease  present  symptoms  of  marked 
ataxia,  tremor  of  the  head  and  extremities,  awkward  chorei- 
form movements,  disordered  speech,  and  nystagmus. 

Friedreich's  disease  presents  absent  knee-jerks,  no  optic 
atrophy,  and  no  palsies  of  ocular  muscles.  Cerel^ellar  ataxia 
is  characterized  by  normal  or  increased  knee-jerks  and  ocular 
symptoms. 

The  treatment  is  merel}'  palliative.  The  disease  is  incur- 
able, and  means  to  keep  the  patient  in  as  good  general  healtli 
as  possible  are  indicated.     The  contractures  which  late  in  the 


678  DISEASES    OF   THE    NERVOUS    SYSTEM. 

disease  lead  to  club-foot  or  other  deformities  may  require  surg- 
ical interference. 

DIFFUSE  DISEASES  OF  THE  SPINAL 
CORD. 

The  dififuse  diseases  of  the  cord  have  no  predilection  for 
either  white  or  gray  matter,  or  for  individual  neuron  systems. 
The  destructive  agent  comes  from  without,  often  by  way  of 
the  blood-vessels  rather  than  by  disease  of  the  nerve  tissue 

itself. 

SPINAL    MENINGEAL    HEMORRHAGE. 

In  this  accident,  also  termed  hematorrhachis,  the  hemor- 
rhages may  be  inside  or  outside  of  the  dura,  the  usual  cause 
being  an  injury,  with  or  without  fracture  of  the  spine.  Severe 
convulsions,  muscular  overexertion,  or  the  bursting  of  a  verte- 
bral aneurism  are  possible  causes.  The  factors  of  hemorrhage 
into  the  cord  (hematomyelia)  are  the  same  as  those  responsi- 
ble for  meningeal  hemorrhage. 

Small  hemorrhage  into  the  membranes  may  cause  no  symp- 
toms. When  the  hemorrhage  is  large  enough  to  cause'  pres- 
sure, the  symptoms  of  root  irritation  will  be  present,  namely, 
pain,  numbness,  tingling,  and  muscular  twitchings.  The  pain 
may  be  a  girdle  pain  about  the  trunk,  or  may  be  referred  to  the 
extremities.  If  the  pressure  increases,  palsy  and  loss  of  sen- 
sation will  supervene.  Disturbances  of  the  sphincters  may 
occur.  The  symptoms  rapidly  reach  their  height,  and  then 
subside  as  the  blood  is  absorbed.  Lumbar  puncture  will  reveal 
blood  in  the  spinal  fluid.  Recovery  may  take  place  to  a  great 
extent,  or  the  patient  may  be  left  with  damage  to  his  spinal 
cord,  the  result  of  extensive  hemorrhage  or  of  severe  pressure. 

The  symptoms  of  hemorrhage  into  the  cord  substance 
greatly  resemble  those  of  hematorrhachis.  They  are  of  sud- 
den onset,  with  numbness,  tingling,  and  a  quickly  oncoming 
paralysis,  both  of  motion  and  sensation,  below  the  seat  of  the 
lesion.  Hemorrhage  into  the  cord  is  prone  to  attack  the  gray 
matter,  and  to  extend  for  long  distances  up  and  down  the  cord 
rather  than  transversely.  Lumbar  puncture  does  not  reveal 
blood  in  the  spinal  fluid.    As  the  clot  is  absorbed,  a  cavity  in 


ACUTE    MYELITIS.  679 

the  central  part  of  the  cord  may  be  left,  resembling  syringo- 
myelia. 

The  history  of  trauma,  a  clean  record  as  to  s^^philis,  and 
the  absence  of  fever,  together  with  the  above  symptoms,  will 
suggest  the  diagnosis.  As  to  treatment,  if  lumbar  puncture 
reveals  blood  in  the  spinal  fluid,  and  the  ^r-ray  picture  shows 
a  fractured  vertebra,  surgical  interference,  other  things  being 
equal,  is  indicated.  If  surgery  is  to  offer  any  hope  of  relief 
to  a  badly  compressed  spinal  cord,  the  operation  should  be 
done  early.  If  the  cord  is  seriously  destroyed,  early  laminec- 
tomy can  do  no  additional  harm,  and  may  help  by  relieving 
pressure  upon  parts  of  the  cord  not  already  injured. 

If  surgical  interference  is  not  undertaken,  absolute  rest 
should  be  carried  out  for  a  period  of  two  or  three  weeks.  Hy- 
perextension  of  the  spine  may  be  applied,  but  great  care  must 
be  used  to  prevent  bed-sores.  The  patient  may  be  rested  upon 
the  chest  and  abdomen  as  much  as  possible,  and  ice-bags  ap-. 
plied  to  the  spine.  After  the  acute  symptoms  have  subsided, 
the  treatment  is  that  of  a  chronic  myelitis. 

EMBOLISM    AND    THROMBOSIS. 

Embolism  and  thrombosis,  although  rare  conditions,  may 
occur  in  the  cord  as  in  other  parts  of  the  body.  Treatment, 
which  is  not  promising,  must  be  directed  to  the  vascular  sys- 
tem, as  in  embolism  or  thrombosis  in  other  parts. 

MYELITIS. 

Diffuse  and  disseminated  inflammatory  lesions  not  due  to 
direct  crushing  or  contusion  of  the  cord  may  be  spoken  of  un- 
der the  term  myelitis.  Myelitis  may  be  acute  or  chronic.  If 
the  gray  matter  alone  is  inflamed,  the  disease  is  termed  polio- 
myelitis ;  if  a  small  vertical  extent  of  the  entire  cord  is  afl:'ected, 
transverse  myelitis ;  if  an  extensive  area  of  both  white  and 
gray  matter,  diffuse  myelitis ;  if  a  considerable  area  of  gray 
matter,  central  myelitis. 

ACUTE    MYELITIS. 

Most  cases  occur  between  the  ages  of  10  and  40  years.  In- 
fections and  intoxications  are  the  most  common  cause,  and 


680  DISEASES    OF   THE   NERVOUS    SYSTEM. 

it  may  follow  almost  any  infectious  disease,  or  occur  in  as- 
sociation with  purulent  foci  in  other  parts  of  the  body.  Over- 
exertion and  exposure  may  act  as  exciting  causes.  A  peculiar 
form  is  observed  in  those  who  work  in  compressed  air — cais- 
son disease.  When  the  patient  passes  too  rapidly  from  an 
atmosphere  of  compressed  air  to  normal  pressure,  gas  is  liber- 
ated in  the  blood,  with  resultant  gas  embolism  in  the  blood- 
vessels, and  because  of  this  there  are  numerous  small  areas 
of  ischemic  softening  in  the  tissues  of  the  cord. 

The  symptoms  come  on  quickly.  The  most  common  type 
is  transverse  myelitis,  and  this  most  frequently  attacks  the 
dorsal  region  of  the  cord.  Usually  the  first  symptom  is  that 
of  numbness  in  the  feet  and  legs,  soon  followed  by  weakness. 
If  the  transverse  lesion  is  complete,  there  is  complete  loss  of 
motion  and  sensation  up  to  a  level  corresponding  to  the  region 
controlled  by  the  segment  of  the  ^cord  afifected.  The  reflexes 
will  be  abolished  in  a  complete  lesion.  The  muscles  of  the 
legs  do  not  atrophy.  Retention  of  urine  will  be  present,  and 
this  necessitates  catheterization. 

If  the  transverse  lesion  is  in  the  lumbar  enlargement  of  the 
cord,  there  will  be  loss  of  control  of  the  sphincters,  and  rapid 
wasting  of  the  muscles  in  the  lower  extremities.  If  the  cerv- 
ical enlargement  be  involved,  the  wasting  of  muscles  will 
occur  in  the  arms. 

In  an  acute  central  myelitis,  muscular  wasting,  paralysis  of 
motion  and  sensation,  and  loss  of  control  of  the  sphincter  will 
be  present.  All  muscles  controlled  below  the  upper  level  of 
the  cord  lesion  will  be  afifected. 

In  the  majority  of  cases  the  myelitis  is  not  complete,  and 
the  resulting  symptoms  are  correspondingly  confused.  Sen- 
sation and  motion  and  sphincter  control  are  not  entirely  lost; 
and  l)oth  deep  and  superficial  reflexes  are  increased  in  the 
incomplete  cases. 

The  chief  aim  of  treatment  is  the  prevention  of  bed-sores 
and  cystitis.  Great  care  should  be  used  in  catheterization, 
since  the  resistance  of  the  bladder  to  infection  is  lessened  by 
the  trophic  disturbance.  A  water-  or  air-bed  is  to  be  preferred, 
and  absolute  rest  in  bed  for  weeks  is  necessary.  Diaphoretics 
and  urinary  antiseptics  may  be  given.     The  treatment  of  the 


COMPRESSION    OF   THE    SPINAL   CORD.  681 

most  favorable  form,  that  due  to  syphilis,  will  be  considered 
in  the  article  on  this  infection.     (See  p.  689.) 

Improvement  has  been  observed  after  lumbar  puncture  in 
some  cases,  but  on  the  whole  outlook  is  unpromising.  Some 
patients  recover  partly.  The  more  severely  and  the  more 
quickly  the  symptoms  arise,  the  more  grave  the  outlook. 
Later  in  the  disease,  small  doses  of  the  iodids,  with  strychnin 
and  the  cautious  use  of  electricity,  are  indicated. 

COMPRESSION    OF   THE    SPINAL    CORD. 

This  affection,  also  known  as  compression  myelitis,  is  an 
interruption  in  the  function  of  the  spinal  cord  due  to  slow 
and  continuous  pressure.  It  may  be  caused  by  disease  of  the 
vertebrae  due  to  tuberculosis,  syphilis,  or  cancer;  by  new 
growths  developing  from  the  spinal  column  or  membranes ; 
by  aneurism  of  the  abdominal  or  thoracic  cavity ;  or  by  the 
growth  of  cysts  within  the  spinal  canal. 

The  spinal  meninges  frequently  are  inflamed  at  the  seat 
of  the  lesion,  and  the  cord  is  thinner  than  normal  at  the  point 
of  pressure.  The  nerve  elements  degenerate  at  the  point  of 
pressure,  and  secondary  degenerations  take  place  in  the  differ- 
ent tracts  of  the  cord. 

The  onset  of  the  symptoms  is  slow,  and  the  first  symptom 
noticed  is  pain  of  a  girdling  type,  due  to  irritation  of  the  pos- 
terior nerve  roots.  Later,  symptoms  of  chronic  myelitis  de- 
velop. The  motor  symptoms,  weakness,  marked  spasticity  of 
muscles,  and  plus  reflexes,  are  apparent  usually  before  serious 
sensory  disturbance  is  observed. 

If  the  compression  be  due  to  caries  of  the  vertebr?e,  suit- 
able surgical  treatment  should  be  applied.  If  due  to  syphilis. 
good  results  will  be  obtained  by  appropriate  therapeutic  steps, 
if  the  case  is  recognized  early.  If  due  to  a  tumor,  the  seat 
of  the  lesion  should  be  located,  and  surgery  applied  to  its  re- 
moval. If  due  to  malignant  growth,  or  aneurism,  treatment 
at  best  can  be  only  palliative.  Proper  attention  should  be 
given  to  the  care  of  the  skin  and  bladder,  as  in  myelitis. 


682  DISEASES    OF   THE    NERVOUS    SYSTEM. 

CHRONIC    MYELITIS. 

This  affection  may  be  either  a  sequel  of  the  acute  forms, 
or  due  to  extensions  from  a  meningitis.  As  a  primar}^  affec- 
tion it  is  rare,  and  in  such  instances  is  attributable  to  alcohol- 
ism, syphilis,  or  exposure. 

The  nervous  tissue  degenerates,  and  the  connective  tissue 
greatly  increases  in  amount.  Secondary  degenerations  de- 
velop, the  blood-vessels  become  thickened,  and,  macroscopic- 
ally,  the  cord  is  smaller  and  harder  than  normal. 

The  symptoms  vary  with  the  location  and  extent  of  the 
lesion  in  the  cord.  In  chronic  dorsal  myelitis,  the  first  symp- 
toms met  with  are  fatigue  in  walking,  stift'ness  of  the  muscles, 
and  paresthesias  in  the  legs.  Actual  pain  is  usually  present 
only  in  a  slight  degree.  All  the  reflexes  are  increased,  and  the 
muscles  more  or  less  spastic.  Bladder  and  rectal  disturbances 
and  impotence  are  present  in  the  late  stages  of  the  disease. 

The  disease  lasts  for  years,  and  is  incurable,  so  that  no 
treatment  is  efficacious.  The  patient  should  be  cautioned 
against  overwork  and  fatigue,  and  must  avoid  inclement 
weather,  and,  if  possible,  live  in  a  warm  climate.  Daily  warm 
bathing  is  beneficial.  A  spinal  fluid  stud}?-  should  be  made  in 
all  cases,  and  positive  findings  of  syphilis  will  call  for  active 
antisyphilitic  treatment.  With  negative  findings,  a  carefully 
watched  course  of  mercury  and  iodids  may  be  of  some  benefit. 
Strychnin  should  be  avoided  where  much  spasticity  is  present. 
The  nutrition  of  the  muscles  may  be  maintained  by  electricity 
and  massage. 

SYRINGOMYELIA. 

Syringomyelia  is  a  rare  affection,  of  obscure  etiology.  It 
develops  early  in  life,  usually  in  subjects  from  twenty  to 
thirty  years  of  age,  as  a  localized  gliosis,  frequently  occupying 
the  central  sections  of  the  spinal  cord.  This  new  growth  ex- 
tends longitudinally  through  the  cord,  outgrows  its  blood  sup- 
ply, the  cells  soften,  break  down,  and  are  absorbed,  leaving  a 
cavity  formation,  surrounded  by  a  wall  of  proliferated  neu- 
roglia of  variable  thickness. 

The  course  of  the  symptoms  is  slow  but  progressive.  The 
usual  site  of  the  incipient  lesion  is  the  cervical  cord,  thus  ac- 


ACUTE    ASCENDING  (LANDRY'S)    PARALYSIS.  683 

counting  for  the  fact  that  the  first  s\mptums  usually  appear 
in  the  hands.  The  picture  is  that  of  progressive  muscular 
atrophy  of  spinal  origin.  xAs  the  lesion  extends,  the  motor 
columns  of  the  cord  are  damaged,  causing  weakness  and 
spasticity  of  muscles,  with  increased  reflexes.  The  picture 
now  resembles  that  of  amyotrophic  lateral  sclerosis,  and  to 
these  symptoms  are  added  disturbances  of  sensation.  The 
pain  and  temperature  fibers  are  destroyed,  as  they  decussate 
in  the  gray  matter  and  anterior  commissure,  while  the  tactile 
fibers  enter  the  posterior  columns  of  the  cord,  and  do  not 
decussate  until  they  reach  the  medulla.  This  causes  dissocia- 
tion of  sensation,  or  loss  of  pain  and  temperature  sense,  with 
preservation  of  the  tactile  sense.  Various  symptoms  develop 
as  other  parts  of  the  cord  are  involved.  The  sensory  disturb- 
ance is  distributed  according  to  the  spinal  cord  segments,  and 
not  according  to  the  nerve  distribution,  as  in  neuritis.  Trophic 
symptoms,  such  as  arthropathies,  fragility  of  the  bones,  skin 
lesions,  and  ulcers  may  develop.  Bed-sores,  cystitis,  and 
sphincter  paralysis  develop  late  in  the  course  of  the  disease. 

The  treatment  of  this  affection  is  purely  palliative,  and 
nothing  is  known  to  cure  or  stay  its  progress.  The  patient 
should  be  protected  from  extremes  of  heat  and  cold,  and 
should  not  overuse  weakened  muscles.  As  a  rule,  the  patient 
suffers  no  pain.  Trophic  lesions,  such  as  ulcers  and  fractured 
bones,  are  to  be  treated  suroicallv. 


ACUTE    ASCENDING  (LANDRY'S)  PARALYSIS. 

Landry's  disease  is  an  acute  progressive  paralysis,  usually 
beginning  in  the  legs,  and  rapidly  extending  upwards  to  in- 
volve the  trunk,  upper  extremities,  and  finally  the  cardiac  and 
respiratory  centers.  It  usuallv  occurs  in  early  adult  life.  It 
presents  no  marked  sensory  change  or  changes  in  the  electrical 
reactions. 

It  is  in  many  respects  analogous  to  acute  poliomyelitis,  and 
is  probably  due  to  some  infectious  agent.  In  some  cases  the 
motor  system  appears  to  be  so  overwhelmed  by  the  toxemia 
that  death  results  before  anatomical  changes  develop  in  the 
nerve  tissue. 


684  DISEASES    OF   THE    NERVOUS    SYSTEM. 

The  treatment  is  wholly  palliative.  The  patient  must  have 
absolute  rest  in  bed,  with  care  of  the  bowels  and  bladder. 
There  is  no  treatment  known  to  check  the  process,  whatever 
it  may  be..  Death  ensues  when  the  medulla  is  reached.  Some 
cases  recover,  but  there  is  no  special  treatment  which  brings 
about  their  recovery.  Supporting  measures  should,  of  course, 
be  used. 

MULTIPLE    SCLEROSIS. 

An  embryologic  defect,  tending  toward  the  proliferation  of 
the  neurogliar  tissue,  is  probably  the  essential  cause  of  most 
cases  of  multiple  sclerosis.  The  acute  infectious  diseases,  in- 
toxications such  as  mercury  and  carbon  monoxid,  grave 
ps3xhic  disturbances,  and  severe  trauma,  all  have  been  as- 
signed as  causal  factors. 

The  disease  is  characterized  by  multiple  lesions  indiscrimi- 
nately distributed  throughout  the  brain  and  spinal  cord;  these 
foci,  macroscopically,  can  be  distinguished  from  the  surround- 
ing tissue.  Microscopically,  many  axis  cylinders  are  seen  to 
be  preserved,  but  very  few  retain  their  medullary  sheath.  The 
neurogliar  tissue  is  increased,  and  does  not  show  any  tendency 
toward  softening.  Secondary  degenerations  are  absent,  and 
ganglion  cells,  even  in  the  center  of  the  foci,  are  not  injured. 

The  cardinal  symptoms  of  a  fully  developed  case  are  a 
coarse  intention  tremor,  nystagmus,  and  scanning  speech.  To 
these  may  be  added  optic  atrophy,  especially  marked  on  the 
temporal  side  of  the  discs,  and  the  symptoms  of  a  spastic  para- 
plegia (spastic  and  weak  muscles,  plus  knee-jerks,  Babinski 
sign,  and  ankle  clonus). 

No  treatment  is  known  that  can  cure  the  disease.  We  can 
only  hope  that  the  particular  case  under  treatment  is  one  des- 
tined to  undergo  a  marked  remission.  It  is  very  important 
that  the  patient  be  thoroughly  rested  and  nourished,  by  forced 
feeding,  if  necessary.  If  anemic,  hematinics  like  iron  and 
arsenic  may  be  used.  The  disease  is  not  painful,  and  does  not 
interfere  with  the  functions  of  the  various  organs  of  the  body. 
Physical  overexertion,  undernutrition,  and  psychic  excitement 
are  to  be  avoided.  The  use  of  alcohol  and  tobacco  should  be 
interdicted. 


THE    MUSCULAR    DYSTROPHIES.  685 

THE    MUSCULAR    DYSTROPHIES. 

The  muscular  dystrophies,  or  myopathies,  are  probably 
due  to  an  intrinsic  disease  of  the  muscles  themselves ;  or,  pos- 
sibly, disease  of  some  of  the  glands  of  internal  secretion,  e.g., 
the  thymus,  may  play  a  causative  role.  They  are  characterized 
by  atrophy  beginning  in  certain  groups  of  muscles,  and  often 
associated  with  a  pseudo-hypertrophy  in  the  same  muscle  or 
in  other  muscles.  In  the  very  early  stages  a  true  hypertrophy 
of  the  muscle  fibers  may  be  present.  In  others  there  is  a  pro- 
liferation of  muscle  nuclei  and  longitudinal  splitting  of  the 
fibers.  There  is  an  increase  of  connective  tissue,  which  takes 
the  place  of  the  atrophied  muscle  fibers.  Extensive  deposits 
of  fat  take  place  in  the  connective  tissue  in  the  pseudo- 
hypertrophic form. 

The  only  known  etiologic  factor  is  heredity,  and  the  dis- 
ease ordinarily  occurs  in  several  generations  of  a  family ;  it 
begins  in  childhood,  as  a  rule,  but  some  cases  appear  in  early 
adult  life. 

The  symptoms  vary  greatly,  and  a  number  of  clinical  types 
have  been  described,  depending  on  the  part  of  the  body  in 
which  the  muscles  are  first  attacked,  the  age  of  onset,  and  the 
occurrence  of  hypertrophy. 

They  may  be  classed  as  the  leg  type,  the  shoulder-girdle 
type,  and  the  face  type,  between  which  three  forms  there  is  no 
sharp  line  of  division.  The  same  famil}'  may  present  each  of 
the  difi^erent  types.  In  all  cases  sensory  symptoms  and  fibril- 
lary tremors  are  wanting,  and  there  is  a  diminution  of  reflexes. 
The  parts  are  cold,  and  deformities  often  develop.  The  leg 
type  especially  presents  the  form  of  muscular  pseudohyper- 
trophy. It  usually  develops  in  a  child  under  the  age  of  10  years, 
the  patient  presenting  enlarg'ed  muscles,  especially  of  the  calf, 
thighs,  and  buttocks,  with  corresponding  weakness  and  awk- 
wardness of  gait.  One  characteristic  sign  of  the  disease  is  the 
way  in  which  the  child  arises  from  the  floor.  He  first  gets  on 
all  fours,  and  gradually  raises  his  body  by  supporting  himself 
with  his  hands  on  his  knees  and  thighs,  thus  "climbing  up  his 
legs"  when  completing  the  act  of  rising. 

The  shoulder-girdle  type  presents  the  disease  in  the  large 
muscles  of  the  shoulder  and  chest,  such  as  the  deltoid,  pec- 


686  DISEASES    OF   THE   NERVOUS    SYSTEM. 

torals,  biceps,  triceps,  and  supra-  and  infra-spinati.  Pseudo- 
hypertrophy may  or  may  not  be  present;  usually  it  occurs 
later  in  life  than  either  the  face  or  the  leg  type. 

The  face  type  usually  begins  early  in  childhood,  and  the 
muscles  of  the  face  are  first  affected,  the  eye  muscles  and 
those  of  mastication  escaping. 

No  cure  of  myopathy  of  the  types  mentioned  is  known. 
The  disease  advances  slowly,  and  the  patient  may  live  for 
many  years. 

Although  treatment  is  of  no  avail,  members  of  a  family  sub- 
ject to  muscular  dystrophy  should  be  advised  of  the  dangers 
of  a  hereditary  taint  affecting  the  succeeding  generation. 
The  children  should  have  the  best  of  care  and  surroundings, 
and  be  protected  from  excessive  fatigue  of  all  kinds.  The 
treatment  of  the  disease  itself,  although  unsatisfactory,  calls 
for  massage  and  electricity,  as  well  as  for  the  use  of  strychnin. 
The  extracts  of  the  thymus  and  pituitary  glands  have  been 
thought  to  do  good  in  some  cases.  For  the  contractures  in- 
cident to  this  aifection  surgery  may  be  resorted  to,  and  tenot- 
omy may  relieve  the  resulting  deformities. 

PROGRESSIVE    NEURITIC    MUSCULAR 
ATROPHY. 

This  form  of  atrophy  usually  begins  in  the  muscles  of  the 
feet,  and  extends  upward.  It  usually  arises  before  the  age  of 
20,  and  is  more  common  in  males  than  in  females.  It  is 
a  hereditary  disease. 

The  nerve  fibers  are  found  to  be  degenerated,  and  an  ex- 
cess of  connective  tissue,  v/ith  proliferation  of  cells,  is  found 
in  the  neurilemma.  The  muscles  show  atrophy  of  their  fibers, 
with  proliferation  of  the  connective  tissue. 

The  symptoms  consist  of  weakness  of  the  muscles  of  the 
foot,  peroneal,  and  anterior  tibial  regions  of  early  develop- 
ment, and  gradually  extending  to  other  muscles  of  both  the 
lower  and  upper  extremities.  The  reflexes  are  diminished, 
and  sensory  disturbances  in  the  form  of  pain,  tenderness  to 
pressure,  and  paresthesia  are  present.  The  affected  limbs  are 
likely  to  be  cold  and  cyanotic. 


SYPHILIS    OF   THE   NERVOUS    SYSTEM.  687 

There  is  no  prospect  of  recovery,  although  the  progress  of 
the  disease  may  be  slow. 

There  is  no  radical  treatment  for  this  type  of  atrophy,  but 
the  use  of  electricity  and  massage  is  indicated  as  a  palliative 
measure.  Deformities  may  result,  which  call  for  tenotomies 
or  braces.    The  weakened  muscles  should  not  be  overfatigued. 

SYPHILIS    OF    THE    NERVOUS    SYSTEM. 

Syphilis  of  the  nervous  system  is  an  infectious  disease  due 
to  the  Treponema  pallidnm.  In  former  years  it  was  customary 
to  speak  of  two  groups  of  syphilitic  disease  of  the  nervous 
system,  the  first  being  characterized  by  specific  or  gummatous 
inflammatorv  lesions  attacking  the  nerve  tissue  and  its  cover- 
ings  by  way  of  the  blood-vessels ;  the  second  group  was 
spoken  of  as  parasyphilitic  disease,  characterized  by  degen- 
eration of  the  nerve  tissue,  and  believed  to  be  due  indirectly 
to  syphilis,  in  from  60  to  90  per  cent,  of  the  cases.  At  the 
present  time  1)0th  groups  are  recognized  as  active  syphilis,  due 
to  the  same  infectious  agent. 

However,  while  the  underlying  cause  is  the  same  in  all 
forms  of  lues  of  the  nervous  system,  we  are  obliged  to  recog- 
nize two  groups  as  dififerent  and  distinct  clinical  affections. 
From  the  standpoint  of  prognosis  and  treatment,  this  distinc- 
tion is  important.  In  the  first  group  the  infection  attacks  the 
nervous  system  by  way  of  the  interstitial  tissues,  and  it  may 
be  spoken  of  as  the  interstitial  form,  or  cerebrospinal  syphilis 
of  the  vessels  and  membranes.  Because  of  the  formation  of 
gummatous  deposits,  and  the  infiltration  of  vessels  and  mem- 
branes, the  first  group  also  may  be  conveniently  spoken  of  as 
the  exudative  form.  In  the  second  group  we  recognize  that 
the  nerve  tissue  itself  is  attacked,  and  it  may  be  referred  to  as 
the  parenchymatous  form,  including  the  diseases,  paresis  and 
tabes  dorsalis. 

One  characteristic  feature  of  interstitial  nervous  syphilis 
is  its  multiplicity  of  symptoms.  In  one  case  the  cranial  nerves 
especially  may  suiTer,  in  another  the  brain,  in  another  the 
spi-nal  cord,  and  in  still  another,  the  entire  cerebrospinal  axis. 
In  brain  syphilis,  a  common  symptom  is  lieadache,  usually 
worse  at  night,  and  preventing  sleep ;  somnolence  during  the 


688  DISEASES    OF   THE   NERVOUS    SYSTEM. 

day  time,  mental  dullness,  irritability,  and  at  times  stupor  or 
delirium  also  occur.  Some  cases  develop  convulsions,  either 
focal  or  general  in  character,  and  some  apoplexy,  generally 
due  to  thrombosis.  Various  cranial  nerves  may  be  attacked, 
especially  the  sixth  and  the  third.  Optic  neuritis  and  choked 
disc  may  occur. 

The  syndrome  of  spinal  syphilis  as  described  by  Erb  is 
the  most  common.  This  is  characterized  by  early  bladder 
disturbance,  usually  a  slowness  in  starting  the  flow  of  urine, 
plus  reflexes,  and  spastic  gait,  with  comparatively  little  spas- 
ticity of  the  leg  muscles  when  the  patient  is  seated.  Pares- 
thesias and  some  irregular  areas  of  sensory  loss  may  be  pres- 
ent. Parts  of  the  cord  other  than  the  lateral  columns  may  be 
attacked.  Implication  of  the  posterior  columns  and  nerve 
roots  may  cause  absent  knee-jerks,  and  lightning  pains  sug- 
gesting tabes.  If  the  lesion  should  interfere  seriously  with 
the  central  part  of  the  cord,  symptoms  of  dissociation  of  sen- 
sation may  develop.  If  the  anterior  horns  are  affected, 
atrophy  takes  place  in  corresponding  muscles,  thus  explaining 
the  occurrence  of  some  cases  of  chronic  progressive  muscular 
atrophy  and  chronic  anterior  poliomyelitis. 

The  diagnosis  of  interstitial  nervous  syphilis  rests  upon 
the  multiplicity  and  irregularity  of  the  symptoms,  which  can 
only  be  accounted  for  by  multiple  lesions,  by  the  fact  that  the 
pains  are  worse  at  night,  and  by  the  study  of  the  blood  and 
spinal  fluid.  The  blood  Wassermann  test  should  be  positive. 
If  the  disease  has  attacked  the  membranes  of  the  cord  and 
brain,  the  spinal  fluid  Wassermann  test  should  be  positive, 
and  the  cell-count  high. 

Tabes  usually  presents  as  early  symptoms  sharp  shooting 
pains  in  various  parts  of  the  body,  such  as  the  legs,  upper  ab- 
domen, bladder  or  rectum,  spoken  of  as  crises;  sluggishness 
in  the  reaction  of  the  pupils  to  light;  and  diminished  or  lost 
reflexes.  Later  the  Argyll  Robertson  pupil  develops,  and  also 
the  ataxic  gait  and  station,  bladder  symptoms,  and  trophic 
disturbances,  such  as  the  Charcot  joint.  The  Wassermann 
reaction  in  the  blood  may  be  absent,  but  commonly  it  is 
strongly  positive  in  the  spinal  fluid,  together  with  increased 
globulin  and  a  cell-count  varying  from  20  to  a  very  large 


SYPHILIS    OF   THE    NERVOUS    SYSTEM.  689 

number  of  lymphocytes,  depending-  upon  the  severity  and  ac- 
tivity of  the  disease  at  the  time  of  examination. 

Paresis  presents  both  mental  and  physical  symptoms.  The 
characteristic  mental  symptom  is  mental  failure  or  dementia. 
The  patient  early  in  the  disease  complains  of  ill  health,  and  his 
early  symptoms  may  strongly  suggest  neurasthenia.  Later 
he  becomes  irritable,  forgetful,  and  shows  loss  of  judgment. 
Some  cases  become  depressed,  and  may  show  delusions  of 
self-blame  resembling  melancholia.  Others  become  exalted, 
with  grandiose  delusions,  which  resemble  mania.  Other  cases 
simply  show  dementia  with  no  delusions.  Among  the  import- 
ant physical  signs  are  disturbances  of  the  pupils,  such  as  the 
Argyll  Robertson  pupil,  irregular  pupils,  and  unequal  pupils 
which  do  not  respond  to  light ;  diminished,  exaggerated,  or 
unequal  knee-jerks;  a  fine  tremor  of  the  lips,  tongue,  and 
hands ;  a  slurring,  drawling,  hesitating  speech,  and  an  irregu- 
lar, shuffling-,  or  ataxic  gait.  Both  the  blood  and  spinal  fluid 
show  a  positive  Wassermann  reaction,  the  latter  having  also 
increased  globulin,  and  a  lymphocyte-count  rarely  above  100 
cells  per  cubic  millimeter. 

The  diagnosis  rests  upon  the  mental  and  physical  signs, 
especially  the  pupillary  signs  and  the  positive  Wassermann 
reaction  in  both  the  blood  and  spinal  fluid,  with  the  presence 
of  increased  globulin  and  lymphocytes  in  the  latter. 

The  prognosis  as  to  the  cure  of  nervous  syphilis  should  be 
guarded  in  the  interstitial  form,  and  is  distinctly  unfavorable 
in  the  parenchymatous  variety. 

TREATMENT. 

In  no  case  of  syphilis  in  the  early  stages  should  we  counsel 
a  discontinuance  of  treatment,  even  though  the  blood  Wasser- 
mann be  negative,  so  long  as  the  spinal  fluid  is  positive. 
Many  cases  of  syphilis  show  nervous  symptoms  a  few  months 
after  the  occurrence  of  the  chancre,  and  in  others  an  examina- 
tion of  the  spinal  fluid  reveals  a  positive  Wassermann  when 
possibly  no  nervous  symptoms  are  present.  Treatment  con- 
tinued and  directed  with  a  knowledge  of  the  condition  of  the 
spinal  fluid  rather  than  of  the  blood  will  probably  prevent 
severe  cases  of  nervous  syphilis  in  later  years. 

44 


690  DISEASES    OF   THE    NERVOUS    SYSTEM. 

Syphilis  is  one  disease  in  whose  management  we  resort 
largely  to  drugs,  which  here  have  an  almost  specific  effect. 
The  most  valuable  drugs  are  mercury,  arsenic,  and  iodin  in 
various  combinations.  The  treatment  of  interstitial  or  cere- 
brospinal syphilis,  to  be  satisfactory,  depends  upon  an  early 
diagnosis.  If  a  large  gumma  has  formed  in  the  brain,  drugs 
will  not  remove  it,  and  the  case  may  have  to  be  treated  surgic- 
ally, as  in  other  brain  tumors.  Again,  if  a  thrombus  due  to 
syphilis  forms  in  a  blood-vessel  of  the  brain  or  cord,  there  will 
be  a  more  or  less  permanent  destruction  of  nerve  tissue  that 
drugs  will  not  remedy.  With  an  early  diagnosis,  such  un- 
toward results  are  lesS  frequent.  Arsenic,  in  the  form  of  sal- 
varsan  ("606")  or  similar  preparations,  should  be  given  in- 
travenously. If  it  is  thought  best  not  to  use  salvarsan,  the 
patient  should  be  put  on  mercury.  This  can  be  given  hypo- 
dermically  in  the  form  of  bichlorid,  calomel,  or  gray  oil,  but 
the  most  effective  method  of  administration  in  nervous  syphilis 
appears  to  be  by  inunction.  The  ordinary  50  per  cent,  blue 
ointment  or  oleate  of  mercury  can  be  used,  from  1  to  as  much 
as  4  drams  (3.9  to  15.5  Gms.)  being  well  rubbed  into  the  skin 
each  day.  It  is  essential  to  place  the  patient  under  the  in- 
fluence of  the  remedy  as  rapidly  as  possible.  If  the  brain  is 
severely  attacked,  it  is  well  at  the  same  time  to  give  rapidly 
increasing  doses  of  some  iodin  preparation,  preferably  sodium 
iodid.  If  the  patient  suffers  from  a  mild  attack,  it  is  well  to 
use  the  mercury  alone  for  a  period  of  about  six  weeks,  this  to 
be  followed  by  a  course  of  gradually  increasing  doses  of  the 
iodids  for  the  same  length  of  time.  These  courses  of  treat- 
ment should  be  repeated  at  intervals,  provided  that  symptoms 
of  active  disease  and  a  positive  Wassermann  in  the  spinal  fluid 
are  still  present. 

In  tabes  and  paresis  or  parenchymatous  nervous  syphilis, 
the  above  method  of  treatment  does  little  good.  For  some 
reason  not  explained,  drugs  which  act  on  syphilis  of  the  exu- 
dative form,  do  not  produce  any  such  result  when  the  spiro- 
chete has  invaded  the  nerve  tissue  itself.  It  has  been  found 
that  with  either  mercury  or  salvarsan  circulating  in  the  blood 
practically  none  can  be  found  in  the  cereorospinal  fluid. 
Efforts  have  been  made  to  devise  some  method  of  medicating 
the  brain  and  cord  directly  by  way  of  the  subarachnoid  space. 


SYPHILIS    OF   THE    NERVOUS    SYSTEM.  691 

The  method  of  Swift  and  EUis  has  proved  to  be  one  of  the 
most  useful.  (C/.  SyphiHs,  p.  84.)  By  this  method  the  pa- 
tient is  first  g-iven  an  intravenous  injection  of  salvarsan  or 
neosalvarsan.  After  an  interval  of  from  twenty  minutes  to 
one  hour,  blood  is  drawn  from  the  vein.  The  blood  is  allowed 
to  stand  overnight ;  the  serum  is  drawn  ofif,  and  then  thor- 
oughly centrifugalated ;  after  this,  it  is  inactivated  at  a  tem- 
perature of  56°  C.  (132.8°  F.).  Ten  to  20  mils  (2.7  to  5.4  f5), 
diluted  with  an  equal  or  double  amount  of  salt  solution,  is 
then  injected  intraspinously.  This  is  usually  given  twenty- 
four  hours  after  the  intravenous  injection.  The  patient  is 
placed  in  lateral  decubitus  in  bed,  with  the  knees  well  drawn 
up,  and  the  head  bent  forward  upon  the  chest.  A  lumbar 
puncture  is  then  made,  and  the  spinal  fluid  allowed  to  drain 
ofif  to  the  amount  of  40  mils  (10.7  f5)  or  more.  In  most  cases 
the  dural  sac  can  be  drained  of  all  the  fluid  that  will  flow. 
The  serum,  warmed  to  body  temperature,  is  then  allowed  to 
enter,  preferably  by  gravity,  through  the  puncture  needle  into 
the  dural  sac.  The  needle  is  then  withdrawn,  the  patient 
turned  on  his  back  without  a  pillow,  and  the  foot  of  the  bed 
raised.  He  is  kept  in  this  position  for  three  hours,  and  then 
allowed  a  more  comfortable  position.  This  treatment  may  be 
repeated  in  two  weeks,  in  most  cases  of  tabes  or  paresis.  The 
reaction  in  tabes  may  be  so  severe,  with  such  severe  crises 
resulting,  that  a  longer  period  of  time  between  the  treatments 
may  be  necessary.  The  patient  should  remain  in  bed  for 
from  one  to  three  days  after  a  treatment. 

In  Ogilvie's  method  40  or  50  mils  (10.7  or  13.4  fo)  of 
blood  are  taken  from  the  patient,  and  the  serum  centrifugal- 
ated.  One-fourth  milligram  of  salvarsan,  dissolved  and  neu- 
tralized in  the  usual  way,  is  added  to  the  serum ;  this  mixture 
is  incubated  at  body  temperature  for  one  hour,  and  then  in- 
activated for  one-half  hour  at  56°  C.  (132.8°  F.).  About  10 
mils  (2.7  fo')  of  this  salvarsanized  serum  are  injected  into  the 
dural  sac,  by  the  technic  just  described. 

Another  method,  which  has  not  been  much  follow^ed  in 
paresis,  is  to  inject  the  serosalvarsan,  as  prepared  by  the  Swift- 
Ellis  method,  directly  beneath  the  intracranial  dura.  Previous 
to  the  injection,  intracranial  pressure  is  reduced  bv  lumbar 
puncture.    The  great  objection  to  this  treatment  is  the  opera- 


692  DISEASES    OF   THE    NERVOUS    SYSTEM. 

tive  procedure  necessary  to  its  application.  Byrnes  advises 
the  use  of  bichlorid  of  mercury,  which  gives  good  results, 
especially  in  tabes.  Many  of  the  foregoing-  methods  do  good 
in  tabes,  and  in  some  cases  the  results  are  striking.  The  more 
early  the  diagnosis  is  made,  and  the  more  acute  the  inflamma- 
tory lesions,  as  indicated  by  a  high  cell-count,  the  more  strik- 
ing are  the  results. 

In  paresis  the  results  are  not  so  encouraging.  If  the  case 
is  seen  early,  and  the  diagnosis  made  while  the  patient  pre- 
sents only  neurasthenoid  symptoms,  with  few  physical  signs, 
the  chances  for  inducing  a  more  or  less  prolonged  remission 
are  good. 

Too  much  stress  cannot  be  laid  on  the  fact  that  mercury 
should  not  be  forgotten  in  treating  all  forms  of  nervous  syph- 
ilis. In  the  light  of  the  knowledge  that  cases  of  tabes  or 
paresis,  receiving  either  mercury  or  arsenic  by  way  of  the  skin, 
mouth,  or  blood-vessels,  rarely  or  never  show  these  drugs  in 
the  cerebrospinal  fluid,  we  began  three  years  ago  to  treat  these 
patients  at  the  Jefferson  Hospital  Nervous  Clinic,  by  draining 
off  the  cerebrospinal  fluid  at  intervals,  with  the  idea  that,  by 
lowering  the  pressure  within  the  cerebrospinal  canal,  we  could 
encourage  the  diffusion  of  these  drugs  from  the  blood  of  the 
capillaries  into  the  cerebrospinal  fluid.  In  carrying  out  this 
treatment,  we  have  used  mercury.  Our  plan  has  been  to  give 
the  patient  suffering  from  either  tabes  or  paresis,  mercury  by 
inunction,  and  to  drain  the  cerebrospinal  fluid  once  every  week 
or  two  weeks. 

We  place  the  patient  in  bed,  drain  by  a  lumbar  puncture 
with  a  Quincke  needle  all  the  fluid  that  will  flow,  usually 
from  15  to  60  mils  (4  to  16  fo).  We  keep  him  in  bed  overnight, 
and  allow  him  to  leave  the  hospital  the  following  morning. 
We  have  not  been  able  to  demonstrate  mercury  in  the  cerebro- 
spinal fluid.  We  have  seen  cases  of  tabes  improve,  both  from 
the  clinical  and  laboratory  standpoint,  just  as  much  when 
treated  by  mercury,  with  systematic  drainage  of  the  cerebro- 
spinal fluid,  as  when  treated  by  the  Swift-Ellis  method  with 
salvarsan.  We  have  seen  remissions  and  improvement  in 
cases  of  paresis,  treated  early.  We  find  that  the  success  of 
the  method  depends  on  the  ability  of  the  patient  to  use  inunc- 
tions to  the  point  of  ptyalization.    His  teeth  must  be  carefully 


SYPHILIS    OF   THE   NERVOUS    SYSTEM.  693 

looked  after,  and  the  mercury  inunction  pushed  to  the  Hmit 
of  tolerance,  and  kept  at  this  point  for  at  least  three  months. 
After  drainage  of  the  cerebrospinal  fluid  a  number  of  times, 
the  patient  improves  in  general  health,  regains  his  weight,  and 
has  less  pain.  The  advantage  of  this  treatment  is  the  simplic- 
ity of  the  technic,  and  usually  the  absence  of  any  severe  re- 
action. Some  patients,  especially  those  with  cerebrospinal 
syphilis,  complain  of  severe  headache  after  drainage.  In  such 
cases  it  is  necessary  to  keep  the  patient  quiet  until  the  head- 
ache subsides.  The  more  skill  employed,  and  the  more  ease 
with  which  the  lumbar  puncture  is  done,  the  less  is  the  lia- 
bility to  headache. 

With  the  present  state  of  our  knowledge  of  tabes  and 
paresis  the  ideal  method  seems  to  be  as  follows : 

1.  Early  diagnosis  before  serious  destruction  of  nerve 
tissue  has  taken  place. 

2.  A  series  of  serosalvarsan  treatments  according  to  the 
Swift-Ellis  method,  the  number  of  these  treatments  to  be  de- 
termined by  Wassermann  tests  of  both  blood  and  spinal  fluid. 

3.  Following  the  serosalvarsan  treatment  a  thorough 
course  of  mercury  by  inunction,  with  the  drainage  of  the  cere- 
brospinal fluid  once  weekly,  for  a  period  of  at  least  three 
months. 

4.  Recognition  of  the  fact  that  nervous  syphilis  is  incura- 
ble with  the  means  at  present  at  our  command,  that  the  pa- 
tient must  be  kept  under  observation,  and  that  the  treatment 
must  be  repeated  as  often  as  the  serological  findings  indicate. 

The  older  methods  of  treatment  in  tabes  and  paresis  are  to 
be  employed  as  indicated.  Whenever  possible  the  patient 
should  be  given  a  thorough  rest  treatment — rest  in  bed,  full 
feeding  and  massage — in  order  to  bring  the  resistance  to  the 
highest  possible  point.  These  patients  should  never  lead 
strenuous  lives,  with  an  excessive  amount  of  hard  work. 
When  the  mental  changes  become  so  marked  that  the  paretic 
no  longer  can  be  at  large,  confinement  in  an  institution  is 
necessary.  The  treatment  here  is  simply  protective,  making 
his  last  days  as  comfortable  as  possible  under  the  circum- 
stances. 

Some  cases  of  tabes  suft'er  from  seA'ere  pains  in  spite  rf  all 
specific  treatment,  and  if  this  be  so  resort  must  be  had   to 


694  DISEASES    OF   THE    NERVOUS    SYSTEM. 

drugs,  such  as  acetphenetidin  and  aspirin,  and  in  severe  cases 
to  morphin,  although  an  opiate  is  to  be  withheld  as  long  as 
possible.  The  pains  frequently  are  relieved  by  drainage  of  the 
spinal  fluid,  and  this  should  be  tried  before  morphin  is  used. 
The  bladder  must  be  watched  for  infection,  and  treated  b}^ 
irrigation  if  there  be  much  pus,  and  drugs  such  as  atropin, 
str3'chnin,  and  urotropin  given  internally.  For  severe  ataxia 
the  persistent  use  of  Frenkel's  method  of  exercise  is  indicated. 

DISEASES  OF  THE  PERIPHERAL 

NERVES. 

PRESSURE    PALSY. 

Long  continued  pressure  upon  a  nerve  may  cause  paralysis 
of  the  muscles  supplied  by  it.  The  musculospiral  is  the  nerve 
most  frequently  affected  because  of  the  not  infrequent  habit 
of  sleeping  with  the  head  resting  upon  the  arm.  Not  uncom- 
monly such  a  palsy  occurs  during  the  heavy  sleep  produced 
by  alcohol.  Other  nerves,  such  as  the  sciatic,  ulnar,  or  an- 
terior tibial  likewise  may  suffer  from  pressure  palsy. 

The  diagnosis  rests  largely  upon  the  history  of  the  case  and 
the  absence  of  pain  and  tenderness  in  the  affected  nerve,  a 
fact  which  distinguishes  the  affection  from  neuritis.  In  mus- 
culospiral palsy,  lead  poisoning  may  suggest  itself,  and  here 
not  only  the  history  of  the  case,  but  the  fact  that  lead  palsy 
is  bilateral,  serve  to  make  the  distinction. 

Rest  of  the  paralyzed  muscles,  massage  and  electricity  con- 
stitute the  treatment.  Strychnin  may  be  given,  but  it  is  of 
little  use.  The  prognosis  is  almost  uniformly  good;  practic- 
ally all  cases  recover  in  a  few  weeks. 

NEURITIS. 

An  inflammation  of  a  single  nerve  trunk  is  spoken  of  as  a 
local  neuritis ;  when  a  number  of  nerves  are  affected,  the  term 
multiple  neuritis  is  applied.  Neuritis  may  be  acute  or  chronic 
and  the  acute  form  may  pass  into  the  chronic. 

The  inflammatory  process  may  be  interstitial,  in  which 
case  the  connective  tissue  is  the  primary  seat  of  the  lesion ;  or 
it  may  be  parenchymatous,  in  which  case  the  nerve  tissue 


LOCAL   NEURITIS.  695 

.itself  is  primarily  affected.  In  the  interstitial  form  the  peri- 
and  endo-  neurium  are  the  first  to  suffer,  and  the  changes  in 
the  nerve  tissue  are  secondary  to  those  in  the  connective  tissue. 
In  the  parenchymatous  form  the  nerve  trunks  are  firmer  and 
grayer  than  normal.  The  myelin  is  segmented  and  divided 
into  drops  and  granules,  and  the  axis  cylinders  become  gran- 
ular and  finally  disappear.  The  nuclei  on  the  sheath  of 
Schwann  proliferate  and  the  nerve  trunk  finally  becomes  a 
fibrous  cord.  Secondary  changes  are  sometimes  found  in  the 
anterior  horn  cells. 

LOCAL    NEURITIS. 

Exposure  to  cold,  extension  of  inflammation  from  sur- 
rounding tissues,  and  trauma  are  the  most  common  causes 
of  a  local  neuritis.     Localized  neuritis  is  usually  interstitial. 

The  symptoms  relate  chiefly  to  pain  along  the  course  of  the 
nerve  and  in  the  part  supplied  by  the  nerve.  This  pain  is 
of  a  dull,  boring  character,  and  made  worse  by  movement  of 
the  affected  part.  The  nerve  is  also  tender  to  pressure.  At 
times  herpes,  edema,  or  redness  of  the  skin  over  the  nerve 
are  present.  The  muscles  supplied  by  the  nerve  are  weak 
and  flaccid,  and  more  or  less  atrophy  may  make  its  appearance. 
Electrical  changes  also  may  be  noted.  These  vary  from  a 
quantitative  change  to  complete  RD.  Various  sensory  dis- 
turbances, paresthesia,  hyperesthesia,  and  at  times  total  anes- 
thesia may  be  present. 

The  duration  of  the  symptoms  depends  among  other  things 
upon  the  severity  and  the  extent  of  the  affection.  Accord- 
ingly it  may  vary  from  a  few  weeks  to  several  years. 

The  diagnosis  rests  especially  upon  the  presence  of  pain 
and  tenderness  of  the  nerve  trunk,  or  in  the  smaller  branches 
in  the  skin  and  muscles.  The  pain  of  neuralgia  is  commonly 
paroxysmal  and  the  nerve  trunk  is  not  tender  to  pressure  ex- 
cept for  a  short  while  after  a  paroxysm  of  pain ;  and  then  the 
nerve  is  sensitive  rather  than  sore  or  tender.  In  spinal  root 
irritation,  again,  the  pain  is  girdle-like  in  distribution  and  the 
nerve  trunks  are  not  tender  to  pressure. 


696  DISEASES    OF   THE    NERVOUS    SYSTEM. 

TREATMENT. 

The  part  of  the  body  in  which  the  inflamed  nerve  is  situ^ 
ated  should  be  put  at  rest,  and  this  rest  should  be  as  nearly 
absolute  -as  possible.  The  earlier  the  diagnosis  is  made  and 
rest  applied,  the  more  rapidly  the  case  recovers.  If,  for  in- 
stance, the  inflamed  nerve  is  in  the  arm,  it  is  preferable  early 
in  the  case  to  put  the  arm  on  a  splint.  Later,  as  the  pain 
subsides,  the  arm  may  be  carried  in  a  sling.  The  part  affected 
may  be  wrapped  in  cotton  and  lightly  bandaged  or  some  cool- 
ing lotion  may  be  applied,  such  as  lead  water  and  laudanum. 

For  the  relief  of  pain,  the  coal-tar  products  and  salicylates 
may  be  given,  or,  if  the  pain  is  very  severe,  opiates  are  de- 
manded. The  constant  galvanic  current  may  be  applied,  the 
positive  pole  being  placed  over  the  inflamed  nerve  for  ten  or 
fifteen  minutes  daily.  Little  dependence,  however,  can  be 
placed  upon  this  expedient.  After  the  acute  symptoms  have 
subsided,  massage,  electricity,  and  strychnin  are  indicated. 
The  use  of  dry  heat  by  means  of  a  dry  hot  air  apparatus  is 
often  of  marked  benefit.  The  massage  should  be  applied  with 
the  view  of  maintaining  the  nutrition  of  the  affected  muscles 
and  nerves ;  electricity  may  likewise  be  used  to  stimulate  the 
affected  nerve  and  muscles.  That  form  of  current  should  be 
used  which  trial  indicates  as  producing  the  best  responses  in 
the  muscles  with  the  least  discomfort  to  the  patient. 

MULTIPLE    NEURITIS. 

Multiple  neuritis  is  probably  always  due  to  some  poison 
circulating  in  the  blood.  The  inflammation  is  usually  of  the 
parenchymatous  form.    Among  the  various  causes  are  : — 

L  Poisons  taken  into  the  body  from  without,  of  which  alco- 
hol, carbon  monoxid,  carbon  bisulphid,  lead,  arsenic,  and 
mercury  are  examples. 

2.  Poisons  generated  within  the  body  in  the  form  of  toxins 
of  infectious  diseases  such  as  influenza,  typhoid  fever,  diph- 
theria, and  pneumonia,  septicemia,  syphilis,  and  tuberculosis. 
Among-  the  multiple  neuritides  due  to  infection,  beriberi  in  all 
probabilit}^  also  should  be  included,  although  its  exact  causal 
relationship  has  not  been  positively  determined. 


MULTIPLE    XEURITIS.  697 

3.  Poisons  generated  within  the  body  because  of  faulty 
metabolism,  such  as  in  gout  and  diabetes,  or  those  which  have 
their  origin  in  pregnancy  and  the  puerperal  state. 

4.  Dyscrasic  blood  conditions,  such  as  chlorosis,  maras- 
mus, cancer,  or  cachexia  from  any  cause. 

The  symptoms  difiter  somewhat  in  different  cases.  In  some 
the  sensory  fibers  suffer  chiefly,  while  in  others  the  motor 
fibers  are  especially  affected,  and  in  others  still  both  sensory 
and  motor  fibers  are  affected.  Again,  in  some  forms  certain 
nerves  especially  are  attacked  such  as  the  musculospirals  in 
plumbism,  the  anterior  tibials  in  alcoholics,  and  the  nerves 
supplying  the  soft  palate  in  diphtheria. 

The  general  symptoms  of  multiple  neuritis  are  similar  to 
those  described  under  local  neuritis.  Pain  and  tenderness 
along  the  course  of  nerve  trunks,  diminished  or  lost  reflexes, 
wasting  of  muscles,  and  sensory  disturbances  are  present  in 
varying  degree.  In  many  cases,  as  might  be  inferred  from 
what  has  been  just  stated,  little  or  no  pain  or  tenderness  can 
be  elicited,  as  in  the  multiple  neuritis  of  lead  poisoning  and  of 
diphtheria.  In  others,  again,  pain  and  tenderness  may  be 
very  pronounced,  as  in  many  cases  of  alcoholic  multiple  neu- 
ritis. Further,  pain  and  tenderness  are  frequently  absent  or 
but  slightly  marked  in  the  larger  nerve  trunks,  but  pro- 
nounced in  the  smaller  branches.  This  is  not  infrequently 
the  case  in  alcoholic  multiple  neuritis.  Here,  indeed,  tender- 
ness is  commonly  elicited  by  forcibly  grasping  the  forearm 
above  the  wrist  or  the  leg  above  the  ankle. 

The  palsies  of  multiple  neuritis  are  in  given  cases  quite 
characteristic,  as  instanced  by  the  paralysis  of  the  palate  and 
nasal  regurgitation  of  liquids  in  diphtheria,  the  double  wrist- 
drop of  lead  poisoning,  and  both  the  double  wrist-drop  and 
foot-drop  of  alcoholic  multiple  neuritis. 

Finally,  it  is  important  to  add  that  in  multiple  neuritis 
the  sphincters  are  never  affected.  This  point  enables  us  at 
once  to  differentiate  this  affection  from  diseases  involving  the 
cord.  The  iris  likewise  escapes,  and  its  reflexes  remain  unim- 
paired. 

TREATMENT. 

In  every  case  the  cause  should  if  possible  be  determined. 
If  the  cause  can  be  discovered  and  eliminated,  as  in  alcoholic 


698  DISEASES    OF    THE    NERVOUS    SYSTEM. 

multiple  neuritis,  the  probability  of  recovery  is  greatly  in- 
creased. In  all  cases  rest  in  bed  and  full  rest  measures  should 
be  applied  (see  p.  584),  A  patient  with  neuritis  attended  by 
severe  pain  will  naturally  seek  the  bed,  but  others,  as  in  those 
following  diphtheria,  may  suffer  little  pain  and  yet  be  greatly 
in  need  of  rest  in  bed.  The  limbs  should  be  supported  upon 
soft  pillows,  or  be  wrapped  in  cotton  and  lightly  bandaged. 
With  absolute  rest  in  bed  and  the  proper  placing  of  the  limbs 
there  will  be  little  need  of  giving  pain-relieving  medicines. 

The  etiology  of  a  given  case,  of  course,  influences  the 
treatment.  If  it  is  due  to  some  poison  such  as  alcohol  or  lead, 
the  elimination  of  the  latter  is  the  first  step.  If  due  to  a 
diathetic  factor,  as  gout,  the  diet  must  be  regulated,  and  anti- 
goutic  remedies  given.  After  the  pain  has  subsided,  or  in  a 
measure  been  relieved,  massage  and  passive  movements  may 
be  instituted.  Later  on  electricity  may  be  employed  to  ex- 
ercise the  muscles.  Strychnin  also  is  useful  but  should  not 
be  given  early ;  at  first  small  doses,  and  later  larger  doses,  may 
be  administered.  Care  should  be  taken  by  means  of  passive 
movements,  and  at  times  by  mechanical  appliances,  to  prevent 
deformities  which  sometimes  result  from  contractures. 

NEURALGIA. 

Neuralgia  is  characterized  by  pain  along  the  course  of  the 
nerve  trunks.  The  pain  is  intermittent  and  usually  severe. 
The  nerve  trunk  is  not  tender  to  pressure  as  in  neuritis,  but 
often  reveals  discrete  painful  points. 

The  causes  of  neuralgia  are  very  numerous.  Diathetic 
causes,  toxins,  vices  of  nutrition,  and  inherited  tendencies  play 
here  a  role.  The  various  poisons  which  are  responsible  for 
the  production  of  neuritis  may  be  factors  in  the  production 
of  neuralgia;  in  addition  to  these  causes  there  are  various 
peripheral  irritations,  of  which  eye  strain,  nasal  and  sinus 
disease,  and  carious  teeth  are  examples.  Furthermore,  it  is 
a  disease  of  adults  and  not  of  children. 

The  important  symptom  of  neuralgia  is  pain,  which  is 
paroxysmal,  sharp,  shooting,  or  burning  in  character.  Be- 
tween the  paroxysms  a  dull  pain  may  persist.  The  pain  is 
increased  or  brought  on  by  irritation,  as  from  cold,  heat,  or 


THE  FIFTH    NERVE.  699 

motion  of  the  affected  part.    Hyperesthesia  is  frequently  pres- 
ent over  the  area  of  nerve  distribution. 

The  diagnosis  rests  upon  the  character  of  the  pain  and  the 
absence  of  the  symptoms  of  other  affections. 

TREATMENT. 

The  general  principles  of  rest  and  feeding — the  stimulation 
of  nutrition — apply  in  this  condition,  as  in  neuritis.  Very 
often  with  the  improvement  in  the  general  health  of  the  pa- 
tient the  pain  disappears.  The  cause  of  the  pain  should  of 
course  be  sought  for  and  removed,  if  possible.  Sources  of 
peripheral  irritation  must  be  borne  in  mind.  Especially  must 
infected  teeth,  nasal,  throat,  and  ear  conditions  be  looked  into. 
If  the  affection  be  the  result  of  arteriosclerosis  little  or  noth- 
ing can  be  accomplished,  as  a  rule.  Great  attention  should 
be  given  to  the  gastro-intestinal  tract,  since  constipation  may 
be  productive  of  neuralgia;  indeed,  the  good  effect  of  repeated 
doses  of  castor  oil  noted  in  some  cases  is  probably  to  be 
accounted  for  by  its  eff'ect  in  overcoming  constipation.  Some 
attacks  of  neuralgia  come  on  periodically,  and  are  relieved  by 
full  doses  of  quinin.  The  salicylates  are  useful  in  many  cases. 
Every  eff'ort  should  be  made  to  avoid  the  use  of  opium,  be- 
cause of  the  obvious  danger  of  establishing  a  habit.  Strychnin 
in  increasing  doses  is  very  valuable,  especially  in  trigeminal 
neuralgia.  Here  its  administration  in  increasing  and  finally 
in  massive  doses  is  often  followed  by  brilliant  results.  Elec- 
tricity is  of  little  use  in  severe  cases. 

DISEASES  OF  SPECIAL  NERVES. 

Diseases  of  the  cranial  nerves  are  usually  associated  with 
diseases  affecting  the  brain  and  its  membranes,  and  their 
treatment  is  that  of  these  diseases.  The  special  exceptions 
to  this  rule  are  the  fifth  and  seventh  cranial  nerve. 

THE    FIFTH    NERVE. 

The  fifth,  or  trigeminal  nerve,  consists  of  two  portions, 
a  motor  and  a  sensory.  The  motor  portion  controls  the  mus- 
cles of  mastication   and   the  tensor  tympani.     The   sensory 


700  DISEASES    OF   THE    NERVOUS    SYSTEM. 

portion  supplies  the  face  and  head  as  far  back  as  the  occiput, 
the  conjunctivae  and  mucous  membranes  of  the  mouth,  tongue, 
upper  pharynx,  teeth,  saHvary,  and  lachrymal  glands.  Paral- 
ysis of  the  fifth  nerve  is  of  rare  occurrence ;  it  does  not  result 
from  exposure  to  cold,  as  does  facial  palsy.  Syphilis,  hemor- 
rhage, trauma  of  the  skull,  and  tumor  may  be  a  cause;  bilat- 
eral hysterical  palsy  may  be  met  with.  Treatment  depends, 
of  course,  upon  the  cause  and  is  based  upon  general  principles. 
Neuralgia  of  the  fifth  nerve  is  characterized  by  pain  in 
one  or  more  of  its  divisions.  Quite  commonly  it  is  accom- 
panied by  tenderness  to  pressure  over  the  infra-orbital  or 
mental  foramina  or  over  the  supra-orbital  notch ;  the  so-called 
points  of  Valleix.  Not  infrequently  the  paroxysms  of  pain 
are  accompanied  by  spasms  or  twitchings  of  the  facial  mus- 
cles, the  affection  being  then  termed  tic  douloureux. 

TREATMENT. 

As  already  insisted  upon,  great  attention  should  be  paid  to 
building  up  the  general  health  of  the  patient;  this  in  some 
cases  will  cause  the  attacks  to  become  less  severe.  In  addi- 
tion, all  sources  of  peripheral  irritation  should  be  carefully 
investigated.  Salicylates  and  coal-tar  products  may  be  used 
to  relieve  the  pain.  Strychnin  in  gradually  increasing  doses 
often  does  good.  The  positive  pole  of  the  constant  galvanic 
current  may  be  tried. 

Not  infrequently  surgical  procedures  must  be  resorted  to. 
Alcohol  may  be  injected  into  the  infra-orbital,  mental  or 
supra-orbital  foramina.  This  frequently  gives  relief  for  many 
months  at  a  time.  In  more  obstinate  cases,  the  injections  may 
be  made  into  the  foramina  of  exit  at  the  base  of  the  skull. 
Again  the  branches  of  the  nerve  may  be  resected,  but  the 
relief  obtained  from  this  procedure  is  not  permanent.  If  the 
resection  is  made  as  near  the  exit  of  the  nerve  from  the  skull 
as  possible  and  is  continued  near  to  its  termination  in  the 
skin — according  to  the  method  of  the  late  W.  J.  Roe — the 
pain  may  not  return.  The  most  radical  procedure  consists 
of  the  removal  of  the  Gasserian  ganglion,  or,  better  still,  the 
evulsion  of  the  sensory  root  of  the  trigeminal.  This,  of 
course,  necessitates  a  severe  operation. 


THE   SEVENTH    NERVE.  701 

THE   SEVENTH    NERVE. 

A  lesion  involving  the  seventh  nerve  produces  paralysis  in 
some  or  in  all  of  the  muscles  supplied.  The  lesion  may  affect 
either  the  central  or  peripheral  neuron,  the  palsy  being-  spoken 
of,  accordingly,  as  central  or  peripheral  facial  paralysis.  A 
lesion  may  attack  the  central  neuron  anywhere  in  its  course 
through  the  brain ;  from  its  origin  in  the  motor  cells  of  the 
precentral  convolution  to  its  end  at  the  facial  nucleus.  The 
peripheral  neuron  may  be  attacked  at  its  origin  in  the  facial 
nerve  nucleus  or  elsewhere  in  the  course  of  the  seventh  nerve. 
The  palsy  resulting  from  a  lesion  of  the  peripheral  neuron  is 
known  as  Bell's  palsy.  The  nerve  may  be  attacked  within  the 
skull,  within  the  fallopian  canal,  or  external  to  the  stylo- 
mastoid foramen. 

Central  palsies  are  due  to  some  brain  lesions,  such  as 
hemorrhage,  tumor,  or  abscess  affecting  the  internal  capsule. 
Consequently  central  facial  palsy  is  commonly  associated  with 
an  ipsolateral  hemiplegia. 

Peripheral  palsies  may  be  due  to  disease  of  the  nucleus, 
to  the  exudation  of  a  meningitis,  to  a  tumor  or  fracture  at  the 
base  of  the  skull,  to  a  neuritis  due  to  trauma,  exposure  to 
cold,  or  to  an  extension  of  inflammation  from  middle-ear  dis- 
ease. The  most  common  causes  of  Bell's  palsy  are  middle-e.ar 
inflammation  and  exposure  to  cold. 

A  central  palsy  usually  does  not  affect  the  muscles  of  the 
upper  part  of  the  face,  and  the  symptoms  relate  to  a  more 
extensive  underlying  condition,  a  hemiplegia.  The  muscles 
are  not  wasted,  and  the  electric  reactions  are  normal.  A  peri- 
pheral palsy  aff'ects  all  of  the  muscles  of  the  side  of  the  face. 
The  eye  cannot  be  closed,  the  forehead  cannot  be  wrinkled, 
the  lower  half  of  the  face  is  flattened  and  flaccid,  while  the 
angle  of  the  mouth  is  drawn  to  the  opposite,  the  sound,  side. 
Subsequently  the  muscles  may  undergo  atrophy,  and  changes 
in  their  reaction  to  the  electric  current  will  be  noted.  Later 
secondary  contracture  of  the  paralyzed  muscles  may  ensue. 

There  is  no  loss  of  sensation,  although  tliere  ma}^  be  some 
pain,  usually  slight  in  character,  about  the  ear  and  mastoid 
process.  If  the  lesion  is  intracranial,  the  eighth  nerve 
also  is  usually  affected,  causing  deafness;  if  the  nerve  is  at- 


702  DISEASES    OF   THE   NERVOUS    SYSTEM. 

tacked  in  the  fallopian  canal,  the  sense  of  taste  is  lost  in  the 
anterior  two-thirds  of  the  tongue,  due  to  implication  of  the 
chorda  tympani ;  if  the  lesion  is  extracranial,  neither  taste  nor 
hearing  is  interfered  with. 

The  differentiation  must  first  be  made  between  a  central 
and  a  peripheral  palsy.  This  usually  presents  no  difficulties ; 
the  fact  that  the  palsy  affects  all  of  the  muscles  in  the  facial 
supply  readily  determines  the  diagnosis. 

TREATMENT. 

The  treatment  of  a  central  palsy  is  that  of  the  disease  of 
which  it  is  a  part,  usually  that  of  hemiplegia.  The  treatment 
of  a  peripheral  palsy  is  satisfactory  in  most  cases.  The  cases 
which  show  a  complete  RD  on  electric  examination  are  the 
ones  which  yield  most  slowly  to  treatment  and  may  require 
care  for  a  year  or  more.  In  some  cases  of  otitis  media  the 
nerve  is  so  damaged  that  it  does  not  recover,  and  in  such 
instances  an  anastomosis  of  the  facial  nerve  with  the  hypo- 
glossal or  spinal  accessory  may  be  considered.  If  the  elec- 
tric examination  shows  only  a  quantitative  loss,  the  patient 
usually  recovers  quickly ;  possibly  in  a  few  weeks,  with  little 
treatment.  In  early  extracranial  cases,  due  to  exposure  to 
cold,  a  blister  may  be  applied  back  of  the  ear,  and  full  doses 
of  salicylates  and  a  brisk  purge  are  indicated.  The  salicylates 
are  of  benefit,  even  although  a  distinct  rheumatic  factor  can- 
not be  determined.  Later,  small  doses  of  the  iodids  may  be 
given.  After  the  acute  symptoms  have  subsided  strychnin 
may  be  given,  %o  to  Y^q  grain  (0.001  to  0.0015  Gm.)  three  or 
four  times  daily.  After  about  ten  days  the  electric  current 
may  be  employed  to  stimulate  the  paralyzed  muscles.  If  the 
case  is  severe  the  interrupted  galvanic  current  should  be  used, 
and  the  best  contractions  are  usually  obtained  by  applying 
the  anode  or  positive  pole  to  the  muscles.  If  the  case  is  mild, 
the  slowly  interrupted  faradic  may  suffice.  The  electric 
treatment  should  not  be  continued  too  long  at  a  sitting  for 
fear  of  exhausting  the  weakened  muscles.  Massage  is  of  more 
importance  than  electricity,  and  should  be  used  from  the  be- 
ginning to  the  end  of  the  treatment.  The  patient  can  usually 
be  taught  to  apply  the  massage  himself;  he  should  be  in- 
structed to  rub  the  face  with  a  circular  motion,  at  the  same 


BRACHIAL    PLEXUS.  703 

time  raising  between  the  thumb  and  fingers  the  muscles  and 
tissues  of  the  face.  The  persistent  use  of  massage  tends  to 
prevent,  or  at  least  to  lessen,  the  contractures  which  may 
develop  in  the  paralyzed  side, 

BRACHIAL    PLEXUS. 

Through  the  brachial  plexus  the  muscles  and  skin  about 
the  shoulder,  arm,  forearm  and  hand  are  innervated.  It  is 
frequently  the  seat  of  injury  by  direct  violence,  or  by  pressure 
exerted  by  a  dislocated  humerus.  In  complete  paralysis  the 
lesion  is  usually  due  to  an  injury  which  ruptures  the  nerves 
in  the  plexus,  or  more  rarely,  tears  the  nerve-roots  from  the 
spinal  cord.  In  complete  lesions,  motion,  sensation,  and 
nutrition  of  the  entire  arm  and  shoulder  are  affected. 

A  partial  plexus  paralysis,  as  originally  described  by  Erb, 
regularly  implicates  the  deltoid,  biceps,  brachialis  anticus,  and 
supinator  longus.  In  some  cases  the  supinator  brevis,  the 
infraspinatus,  and  the  subscapular  are  paralyzed,  and  in 
examples  of  this  sort  the  lesion  is  supposed  to  afifect  the  fifth 
and  sixth  cervical  nerves  or  the  upper  trunk  of  the  brachial 
plexus.  Trauma  is  the  usual  cause  of  such  a  paralysis.  The 
so-called  obstetric  paralysis  is  supposed  to  be  due  to  stretch- 
ing of,  or  pressure  upon,  this  part  of  the  plexus  during 
birth. 

Klumpke's  paralysis  implicates  the  eighth  cervical  and  first 
thoracic  nerves,  and  the  symptoms  produced  are  manifest  in 
the  small  muscles  of  the  hand  and  the  flexors  of  the  forearm. 
At  the  same  time,  due  to  disease  of  the  ramus  communicans, 
there  is  a  paralysis  of  the  sympathetic  upon  the  same  side, 
evidenced  especially  by  retraction  of  the  eyeball  and  con- 
traction of  the  pupil. 

The  outlook  in  these  forms  of  paralysis  depends  on  the 
extent  of  the  original  lesion.  In  total  paralysis,  which  usu- 
ally means  a  rupture  of  nerve-trunks,  the  outlook  is  naturallv 
very  unfavorable.  In  the  upper  arm  type,  especialh^  in  ob- 
stetric paralysis,  there  is  a  tendency  toward  improvement,  the 
extent  of  which,  of  course,  depends  upon  the  severity  of  the 
injury.  The  same  rule  applies  to  paralysis  of  the  lower  arm 
type.    If  the  lesions  are  due  to  a  new  grov^-th  or  to  any  other 


704  DISEASES    OF   THE    NERVOUS    SYSTEM. 

progressively  increasing  cause,  the  outlook  is,  of  course, 
unfavorable. 

Both  neuritis  and  neuralgia  of  the  brachial  plexus,  affecting 
one  or  all  branches  of  the  plexus,  are  not  uncommon.  Trauma 
not  so  severe  as  to  produce  paralysis  may  be  a  cause.  Rheu- 
matism is  a  not  infrequent  factor.  Neuralgia  may  be  due  to 
any  of  its  various  causes,  but  in  such  cases  the  possibility  of  a 
direct  irritation  of  the  cervical  nerve-roots  must  always  be 
borne  in  mind. 

The  diagnosis  of  a  neuritis  depends  upon  the  presence  of 
pain  upon  pressure  along  the  nerve-trunks,  pain  upon  motion 
of  the  shoulder  and  disturbance  of  motion,  sensation,  and 
nutrition  of  the  parts  supplied.  The  diagnosis  of  neuralgia 
depends  upon  the  presence  of  pain  with  the  absence  of  the 
signs  of  neuritis. 

TREATMENT. 

If  a  complete  RD  in  the  muscles,  with  total  loss  of  motion 
and  sensation,  is  present  and  continuous,  the  evidence  tends 
to  show  that  nerve-trunks  are  completely  severed  and  sur- 
gical intervention  offers  the  only  possible  remedy.  In  other 
cases  the  use  of  massage  and  electricity  and  all  measures 
which  help  the  nutrition  of  the  nerves  and  muscles  are  in- 
dicated. 

In  brachial  neuritis  an  early  diagnosis  and  institution  of 
treatment  are  important.  The  first  essential  is  complete  rest, 
preferably  by  placing  the  patient  in  bed,  and  properly  support- 
ing the  arm.  In  other  instances  the  arm  may  be  placed  in  a 
sling  or  bandaged  to  the  side  of  the  chest.  Among  drugs  the 
salicylates  are  of  benefit  in  most  cases.  The  local  application 
of  heat,  either  moist  or  dry,  is  of  decided  benefit.  Electricity 
in  the  form  of  the  continuous  galvanic  current  applied  with 
the  positive  pole  to  the  painful  nerves,  may  also  give  some 
relief.  As  soon  as  the  acute  symptoms  have  subsided  the 
shoulder  and  arm  should  be  treated  by  massage.  Benefit  may 
be  obtained  by  rubbing  in  an  ichthyol  ointment,  although  it 
is  probable  that  the  rubbing  and  not  the  ichthyol  is  of  benefit. 
Electricity  also  should  now  be  applied.  The  arm  should  be 
supported  by  a  sling  until  the  symptoms  have  largely  sub- 
sided, inasmuch  as  the  pulling  and  stretching  of  the  nerve 


LUMBAR   AND    SACRAL   NERVES.  705 

trunks  which  ensue  in  moving  the  arm  and  shoulder  may  irri- 
tate and  again  produce  pain  and  tenderness  in  the  affected 
parts.  Full  feeding,  general  tonics,  iron  and  strychnin  will 
prove  useful  in  the  later  stages. 

The  treatment  of  a  brachial  neuralgia  follows  the  general 
principles  already  considered.  Rest  is  essential,  and  the  more 
complete  the  rest,  the  less  frequent  the  paroxysms  of  pain.  If 
due  to  a  toxic  cause,  such  as  malaria,  a  rheumatic  or  gouty 
diathesis,  drugs  appropriate  to  such  conditions  are  indicated. 
A  thorough  search  for  peripheral  causes  of  irritation  should 
always  be  made. 

AFFECTIONS  OF  INDIVIDUAL  ARM  NERVES. 

The  median,  ulnar,  musculospiral,  and  circumflex  nerves 
are  frequently  subject  to  injury.  The  musculospiral,  because 
of  its  location,  is  most  frequently  injured  by  pressure.  This 
usually  is  brought  about  by  the  patient  sleeping  with  his 
head  on  his  arm  while  under  the  influence  of  alcohol.  The 
outlook  is  good  in  these  forms  of  pressure  palsy,  the  patient 
recovering  in  a  few  weeks  under  treatment  with  massage  and 
electricity. 

If  in  a  wound  of  the  arm  any  of  these  nerve-trunks  are 
severed  they  must  be  treated  from  the  surgical  standpoint, 
followed  by  a  prolonged  course  of  electricity  and  massage. 

DORSAL    NERVES. 

The  most  common  affection  of  the  dorsal  nerves  is  inter- 
costal neuralgia,  the  general  causes  and  treatment  of  which 
have  already  been  outlined.  Local  neuritis  may  arise,  followed 
by  herpes,  which  usually  gives  much  pain  and  discomfort. 
General  measures  to  combat  any  gouty  or  alloxuric  diathesis 
are  indicated.  The  herpes  must  be  treated  locally,  with  the 
idea  of  keeping  the  skin  dry,  and,  as  far  as  possible,  to  prevent 
infection  of  the  vesicles. 

LUMBAR    AND    SACRAL    NERVES. 

Lesions  of  the  lumbar  and  sacral  nerves  and  plexuses  are 
not  as  common  as  those  of  the  brachial  plexus.     They  may 

45 


706  DISEASES    OF   THE   NERVOUS    SYSTEM. 

be  affected  in  disease  of  the  vertebrse,  by  various  injuries,  by 
growths  within  the  spinal  canal,  and  by  lesions  in  the  pelvis 
or  in  the  course  of  the  nerves.  The  results  of  the  lesions  are 
similar  to  those  noted  elsewhere.  In  a  general  neuritis  these 
nerves  may  participate  in  the  general  inflammatory  process. 

The  most  important  affection  of  the  nerves  of  the  lower 
extremity  is  sciatica.  The  sciatic  nerve  may  be  the  seat  of 
an  intense  neuralgia.  The  pain  may  be  diathetic  in  origin,  or 
due  to  some  irritation  in  the  pelvis,  such  as  a  local  pressure. 
Very  frequently  a  neuritis  is  present.  The  inflammation  pri- 
marily affects  the  sheath  of  the  nerve,  but  often  extends  to  the 
interstitial  tissue,  and  may  secondarily  invade  the  nerve  fibers. 
The  pain  is  usually  most  severe  at  the  sciatic  notch  and  in 
the  middle  of  the  thigh. 

Sciatica  most  commonly  occurs  at  middle  life  or  later,  and 
is  more  frequent  in  males  than  females.  It  is  most  likely  to 
occur  in  those  with  a  tendency  to  a  gouty  or  rheumatic  dia- 
thesis, whatever  the  latter  may  mean.  Many  cases  appear  to 
follow  exposure  to  cold  and  wet. 

The  most  marked  symptom  is  pain  and  tenderness  to  pres- 
sure along  the  nerve-trunk.  The  pain  is,  as  already  stated, 
most  marked  at  the  notch,  but  discrete  points  may  be  found 
along  the  course  of  the  nerve  and  at  its  divisions  into  the 
external  and  internal  popliteal  branches.  By  forcibly  flexing 
the  thigh  on  the  trunk  with  the  leg  extended,  and  thus  stretch- 
ing the  nerve,  tenderness  at  and  below  the  sciatic  notch  is 
readily  elicited.  The  pain  may  be  dull  and  boring  in  char- 
acter and  may  be  absent  when  the  patient  is  at  rest.  It  may 
come  on  in  paroxysms  simulating  a  neuralgia.  The  onset  is 
usually  gradual.  The  pain  may  extend  throughout  the  entire 
distribution  of  the  nerve  and  its  branches.  Numbness,  ting- 
ling, and  formication  are  often  complained  of.  Anesthesia  is 
not  found  except  in  very  severe  cases.  As  the  disease  pro- 
gresses, weakness  and  wasting  of  the  leg  muscles  may  develop. 
Trophic  and  vasomotor  disturbances  may  occur,  as  shown  by 
the  appearance  of  herpes  and  edema. 

The  presence  of  pain  along  the  course  of  the  nerve,  tender- 
ness on  pressure  and  on  extension,  and  the  absence  of  any 
other  condition  on  A'-ray  and  pelvic  examinations,  will  be 
sufficient  to  establish  the  diagnosis  of  sciatica. 


LUMBAR   AND    SACRAL   NERVES.  707 

TREATMENT. 

The  treatment  of  sciatica  may  be  considered  under  two 
heads:  (1)  The  treatment  of  acute  or  recent  sciatica;  (2) 
the  treatment  of  the  chronic  or  estabhshed  form. 

The  first  indication  in  the  treatment  of  the  acute  form  is 
rest  in  bed.  The  Hmb  should  be  wrapped  in  flannel  bandages 
and  fixed  upon  a  well  padded  splint  in  a  position  of  moderate 
extension.  The  intestinal  tract  should  be  emptied  by  a  free 
saline  purge.  It  is  necessary  that  a  bed-pan  be  used  in  order 
to  maintain  as  perfect  rest  as  possible,  and  to  avoid  disturbing 
the  splint.  The  pain  usually  decreases  rapidly  with  complete 
rest,  and  there  will  be  little  necessity  for  the  use  of  morphin. 
If  pain  persists  in  spite  of  the  splint,  relief  may  be  obtained 
by  the  local  application  of  heat  and  by  giving  the  coal-tar 
products,  such  as  antipyrin  or  acetphenetidin^  and,  exception- 
ally, morphin. 

Most  cases  are  benefited  by  the  free  administration  of  one 
of  the  salicylates.  They  should  be  pushed  to  the  physiologic 
limit,  and  their  unpleasant  effects  mitigated  by  combining 
them  with  the  bromids.  Ten  grains  (0.65  Gm.)  of  sodium 
salicylate  may  be  given  with  the  same  dose  of  sodium  bromid 
every  four  hours.  Later  on  small  doses  of  the  iodids  and 
mercurials  may  be  given  instead  of  the  salicylates.  However, 
too  much  emphasis  cannot  be  laid  upon  rest  as  the  essential 
factor  in  the  treatment  of  acute  sciatica.  The  patient  should 
continue  to  rest  in  bed  for  some  time — several  days  or  weeks 
— after  the  pain  has  disappeared. 

Most  patients  come  under  treatment  after  the  condition 
has  become  chronic,  and  in  such  instances  a  prolonged  rest  in 
bed  for  from  six  to  eight  weeks  or  more  is  necessary  to 
obtain  good  results.  As  in  the  acute  case,  the  affected  limb 
should  be  put  in  a  splint.  Massage  should  be  employed  as 
soon  as  the  pain  subsides  enough  to  permit  it,  light  massage 
being  used.  A  suitable  form  of  electricity  may  be  applied, 
and  local  heat,  preferably  dry  heat,  is  of  great  benefit. 

The  patient  may  be  given  a  course  of  salicylates  followed 
later  by  the  iodids,  or  the  iodids  mav  be  given  in  small  doses 
with  the  salicylates,  from  the  l^eginning.  At  the  same  time 
a  suitable   diet,   excluding   red   meats,    sugars   and    starches. 


708  DISEASES    OF   THE   NERVOUS    SYSTEM. 

should  be  instituted,  while  full  feeding  should  be  brought 
about  by  the  addition  of  milk  in  gradually  increasing  quan- 
tities. 

la  intractable  cases,  stretching  of  the  nerve  after  exposure, 
by  surgical  means,  may  be  resorted  to,  although  this  is  rarely 
necessary  or  justifiable.  The  same  may  be  said  of  acu- 
puncture. 

COCCYGODYNIA. 

Persistent  pain  about  the  coccyx  is  a  distressing  condi- 
tion. It  usually  occurs  in  patients  who  are  in  an  exhausted 
physical  condition,  and  is  often  a  part  of  a  neurasthenic  or 
hysteric  syndrome.  It  may  occur  in  patients  with  a  gouty  or 
rheumatic  diathesis.  In  the  treatment  of  this  affection  rest  is 
most  essential.  Electricity,  especially  the  galvanic  current,  is 
useful  in  many  cases.  If  a  rheumatic  diathesis  be  determined, 
a  course  of  salicylates  should  be  given.  Massage  may  be 
employed,  at  first  gently,  and  later  more  vigorously.  Resting 
upon  an  air-cushion  when  sitting  may  give  relief.  Some 
writers  recommend  counterirritation.  However,  with  a  thor- 
ough rest  treatment,  such  measures  are  rarely  necessary. 
Finally,  we  should  not  lose  sight  of  the  fact  that  disease  of 
the  bone  may  be  present,  and  may  require  surgical  inter- 
ference. ^ 

VASOMOTOR  AND  TROPHIC  DISEASES. 

RAYNAUD'S    DISEASE. 

Raynaud's  disease  is  characterized  by  paroxysmal  vaso- 
motor disturbances,  most  frequently  affecting  the  digits.  The 
first  stage  is  one  of  syncope,  during  which  the  parts  become 
cold  and  the  seat  of  considerable  or,  perhaps,  severe  pain. 
This  stage  may  last  from  a  few  minutes  to  several  hours,  and 
is  followed  by  the  gradual  onset  of  the  stage  of  local  asphyxia, 
during  which  the  part  becomes  congested,  and  varies  in  color 
from  dusky  blue  to  almost  black.  In  this  stage  the  pain  is 
severe,  and  may  become  unbearable.  The  affected  part  feels 
cold,  and  sensation  may  be  dulled  or  absent.  After  a  few 
minutes  the  discoloration  fades  and  the  normal  color  returns 
gradually,  the  part  first  affected  being  the  part  first  restored. 


RAYNAUD'S    DISEASE.  709 

as  a  rule.  The  cyanosis  changes  to  purple,  to  pink,  and  then 
to  a  hyperemic  redness.  If  this  stage  continues  for  several 
hours,  small  blebs  may  appear  upon  the  part  affected,  followed 
by  ulceration  and  gangrene.  The  lingers  and  toes  are  the 
parts  most  frequently  affected,  but  other  regions,  such  as  the 
nose,  ears,  lips,  and  patches  of  skin  over  various  parts  of  the 
body  may  suffer.  Symmetrical  parts  of  the  body  are  usually 
attacked,  hence  the  term  ''symmetrical  gangrene."  The  vaso- 
motor symptoms  vary,  and  may  not  always  follow  those  of  a 
typical  case.  The  individual  attack  may  last  a  few  minutes, 
several  hours,  or  even  days.  The  patient  may  have  but  a 
single  attack ;  the  seizures  may  be  repeated  irregularly  for 
several  years.  Hemoglobinuria  may  occur  during  the  attack 
or  it  may  be  the  only  symptom. 

No  distinct  cause  is  known.  A  neuropathic  heredity  and 
general  debility  from  any  cause  seem  to  be  factors.  The  most 
common  exciting  cause  is  exposure  to  cold.  Grief,  fright  and 
trauma  appear,  at  times,  to  bring  on  the  attack.  It  may  be 
associated  with  other  vasomotor  disturbances.  The  under- 
lying condition  is  obscure.  The  syncope  is  produced  by  con- 
traction of  the  blood  vessels,  the  asphyxia  by  dilatation  of  the 
capillaries  and  small  veins. 

Everything  should  be  done  to  build  up  the  general  health 
of  the  patient.  Children  with  a  neuropathic  taint  should  be 
brought  up  to  lead  open-air  lives  and  to  follow  outdoor  occu- 
pations. Bathing  should  be  used  for  its  tonic  effect.  Coffee, 
tea,  alcohol,  and  tobacco  should  be  excluded.  The  diet  should 
be  liberal,  and  milk  should  be  taken  freely.  Constipation 
should  be  guarded  against.  If  malaria  or  syphilis  is  found  in 
the  patient,  it  must  be  treated  vigorously  with  appropriate 
remedies.  Quinin  has  seemed  to  be  of  value  in  cases  not 
malarial.  Sudden  changes  of  temperature,  and  exposure  to 
cold  should  be  avoided,  and  warm  clothing  worn,  with  the 
extremities  well  protected.  Linen  socks  and  underwear  next 
to  the  skin,  with  woolen  socks  and  underwear  over  these,  have 
been  found  of  distinct  advantage.  Mittens  are  warmer  than 
gloves  for  the  hands. 

Warm  applications  should  be  applied  during  the  stage  of 
syncope.  Nitroglycerin  is  valuable  during  this  stage.  Mor- 
phin  may  be  given  if  the  pain  is  severe.     In  the   stage   of 


710  DISEASES    OF   THE    NERVOUS    SYSTEM. 

asphyxia  the  part  should  be  wrapped  in  cotton-wool  and  ele- 
vated, if  possible. 

Electricity  may  be  of  some  benefit.  This  can  be  given  in 
the  form  of  the  constant  current,  by  placing  the  affected  part 
in  a  basin  of  salt  water,  and  placing  the  cathode  in  the  water 
while  the  anode  is  applied  to  the  spine.  Cushing's  plan  of 
treatment  consists  of  applying*  an  elastic  bandage  to  the  limb 
during  the  stage  of  syncope  tight  enough  to  stop  the  arterial 
circulation ;  after  several  minutes  the  bandage  is  loosened, 
when  the  part  usually  becomes  red.  This  procedure  may  have 
to  be  repeated  in  severe  cases.  If  gangrene  occur,  surgical 
measures  may  be  necessary. 

ANGIONEUROTIC    EDEMA. 

This  affection  is  characterized  by  circumscribed  swellings 
of  the  subcutaneous  or  submucous  tissues.  The  swellings 
may  be  small  in  extent  or  may  affect  an  extremity  or  one- 
half  of  the  face.  It  is  known  as  acute  circumscribed  edema, 
giant  urticaria,  and  Quincke's  disease.  It  may  be  hereditary 
and  is  often  recurrent.  It  is  commonly  associated  with  gastro- 
intestinal disturbance. 

The  chief  symptom  of  this  condition  is  a  characteristic 
swelling,  which  usually  comes  on  quickly  without  warning. 
It  reaches  its  maximum  in  one-half  to  two  hours.  The  bor- 
ders may  be  sharply  defined  or  shade  into  the  surrounding 
tissue.  The  color  usually  is  whitish  or  waxy.  The  center  of 
the  swollen  area  may  extend  one-half  inch  above  the  sur- 
rounding skin.  There  are  few  subjective  sensations  in  the 
swollen  region,  except  a  feeling  of  fullness,  stiffness,  and,  in 
some  cases,  burning  or  itching.  No  objective  sensory  changes 
are  found.  Any  part  of  the  body  may  be  affected,  although 
the  face,  extremities,  and  genitalia  are  the  most  common  sites 
of  the  swellings.  The  distribution  is  irregular.  The  swellings 
may  last  a  few  minutes  only  or  several  hours  or  days.  There 
is  a  pronounced  tendency  to  recurrence.  The  swellings  of 
the  mucous  membranes  are  the  most  troublesome,  especially 
those  of  the  tongue,  pharynx,  or  larynx.  The  secretion  of 
urine  may  be  increased,  and  it  may  contain  albumin  and  hemo- 
globin. Between  attacks  the  health  is  usually  good.  In  some 
of  the  congenital  cases  the  swellings  may  be  permanent. 


INTERMITTENT    CLAUDICATION.  /U 

The  pathology  of  the  disease  is  not  well  understood. 
Heidenhain  believes  that  capillary  cells  play  the  chief  role  in 
lymph  formation,  and  that  morbid  influences  may  lead  to 
excessive  secretion  and  production  of  swelling.  Some  think 
chemical  processes  have  a  causative  relation.  The  family 
forms  of  the  disease  are  apt  to  appear  at  an  early  age,  and 
show  a  wider  range  of  symptoms. 

TREATMENT. 

The  patient  should  be  kept  in  the  best  possible  physical 
condition,  and  an  efifort  made  to  remove  any  physical  or 
psychic  cause  that  tends  to  lessen  the  subject's  nervous  resist- 
ance. Rest,  diet,  exercise,  and  bathing  all  must  be  carefully 
regulated  with  this  end  in  view.  Many  drugs  have  been  used, 
but  none  are  specific.  Strychnin  does  good.  Atropin  is  use- 
ful during  the  attack.  Osier  has  seen  good  results  from  nitro- 
glycerin. Cold  must  be  avoided.  With  albumin  or  hemo- 
globin present  in  the  urine,  rest  and  a  low  diet  should  be  in- 
sisted upon.  Calcium  chlorid  or  calcium  bromid,  0.6  to  1 
gram  (9  to  15  gr.)  three  or  four  times  daily  have  been  recom- 
mended. Oppenheim  speaks  of  two  cases  cured  and  one 
helped  by  the  use  of  quinin.  For  the  relief  of  the  swellings 
collodion  may  be  tried,  or  compression  by  an  elastic  bandage. 
Edema  of  the  glottis  may  require  scarification  or  tracheotomy. 
Spraying  with  a  1 :  10,000  aqueous  solution  of  adrenalin  may 
be  tried. 

INTERMITTENT    CLAUDICATION. 

This  condition  is  not  considered  a  neurosis,  although  some 
authors  incline  to  the  view  that  a  blood-vessel  spasm  may  be 
present.  Others  think  the  condition  is  one  of  arteriosclerosis. 
Probably  a  combination  of  the  two  conditions  is  present. 

Exposure  to  cold,  the  excessive  use  of  tobacco  and  alcohol, 
and  less  frequently,  syphilis,  are  given  as  causes  of  this  dis- 
ease, which  usually  attacks  men  of  middle  or  more  advanced 
age. 

The  symptoms  consist  of  weakness  and  cramps,  usually  of 
the  legs,  more  rarely  of  the  arms,  provoked  by  a  moderate 
amount  of  exertion.  Numbness  and  various  paresthesias  ar^ 
present.    The  severity  of  the  attack  forces  the  patient  to  rest. 


712  DISEASES    OF   THE   NERVOUS    SYSTEM. 

In  a  few  minutes  he  may  be  able  to  walk  again  for  a  short 
distance,  the  exertion,  however,  bringing  on  another  attack. 

In  cases  with  sclerosis  of  the  peripheral  vessels,  there  is 
an  absence  of  pulsation  in  the  posterior  tibial  arteries  or  in  the 
dorsalis  pedis  arteries.  If  the  vascular  sclerosis  is  marked  in 
the  spinal  arteries  the  reflexes  are  increased,  and  there  is 
bladder  disturbance  during  the  attack.  The  diagnosis  rests 
upon  the  history  of  the  case,  the  peculiar  symptoms  on  exer- 
tion, and  on  examination  of  the  dorsalis  pedis  and  posterior 
tibial  arteries.  The  course  is  chronic,  and  lasts  for  years.  Im- 
provement frequently  takes  place,  but  recovery  is  rare.  The 
patients  usually  succumb  to  some  other  arteriosclerotic  dis- 
turbance. 

The  treatment  of  intermittent  claudication  is  unsatisfactory. 
The  patient  should  have  physical  rest,  and  should  abstain  from 
alcohol  and  tobacco.  Local  vasodilators,  as  electric  foot-baths, 
are  recommended.  Internally,  the  use  of  the  iodids  and  the 
nitrites  is  indicated. 

PROGRESSIVE    FACIAL    HEMIATROPHY. 

This  rare  affection  is  characterized  by  wasting  of  the  skin, 
soft  parts,  and  even  of  the  bones,  of  one  side  of  the  face.  It 
may  be  limited  to  part  of  the  face,  or  it  may  affect  the  shoulder, 
upper  arm,  and  chest  on  the  same  side  as  the  face. 

The  cause  of  the  disease  is  not  known.  It  usually  de- 
velops between  the  ages  of  ten  and  twenty.  Wounds  of  the 
face,  extraction  of  teeth,  and  infectious  diseases  all  have  been 
given  as  causes. 

The  first  symptom  usually  is  the  development  of  a  whitish 
or  pigmented  patch  about  the  eye,  cheek,  or  forehead.  The 
skin  becomes  thin  and  shiny,  and  often  brown  or  yellowish. 
The  subcutaneous  tissue  gradually  shrinks,  the  affected  side 
of  the  face  sinks  in,  and  the  deformity  becomes  apparent. 
The  hair  falls  out,  the  bones,  and,  to  a  slight  degree,  the  mus- 
cles are  affected,  though  RD  is  not  present.  The  sebaceous 
glands  atrophy,  but  their  secretion  is  not  checked,  and  per- 
spiration may  be  normal  or  increased.  The  atrophy  may 
affect  the  tongue,  hand,  soft  palate,  uvula,  and  gums.  Neu- 
ralgic pains  and  paresthesias  may  occur  in  the  early  stages 


SCLERODERMA.  713 

of  the  disease.  The  skin  in  late  stages  has  a  roughened, 
wrinkled  appearance.  The  eyeball  is  sunken,  and  the  palpe- 
bral fissure  narrowed.  Hemihypertrophy  is  the  opposite  con- 
dition, concerning  the  cause  of  which,  likewise,  little  is  known 
as  yet. 

A  degenerative  neuritis  of  the  trigeminus  has  been  found, 
e.g.,  in  the  case  of  Virchow  and  Mendel.  Numerous  theories 
have  been  advanced  as  to  the  pathology  of  the  disease,  but 
nothing  definite  is  known. 

The  disease  does  not  shorten  life,  and  there  is  little  dis- 
turbance, as  a  rule,  beyond  the  deformity  produced  by  the 
atrophy.  No  treatment  is  known  to  be  of  benefit.  Tonics  and 
galvanism  may  be  given  a  trial. 

SCLERODERMA. 

This  affection  is  characterized  by  a  hardening  of  the  skin 
and  subcutaneous  tissues,  either  diffuse,  affecting  the  greater 
part  of  the  body,  or  circumscribed  in  irregular  patches,  bands, 
or  rings  following  the  distribution  of  peripheral  nerves  or  of 
spinal  segments.  The  circumscribed  form  is  known  as  mor- 
phea or  Addison's  keloid.  The  parts  of  the  skin  and  sub- 
cutaneous tissues  attacked  undergo  atrophy. 

It  is  most  common  in  the  female  sex.  Age  has  no  influence. 
It  has  been  thought  to  follow  infectious  diseases,  syphilis,  ex- 
posure to  extremes  of  temperature,  and  mental  and  physical 
exhaustion. 

Nothing  definite  is  known  in  the  pathology  of  the  disease. 
Increase  of  connective  tissue  and  changes  in  the  blood-vessels 
of  the  skin  have  been  found.  The  thyroid  has  been  found 
atrophied.  Not  infrequently  a  positive  Wassermann  is 
present. 

The  symptoms  usually  come  on  slowly.  Before  the  changes 
in  the  skin  the  patient  may  complain  of  pains  in  the  joints. 
Not  infrequently,  if  the  patient  comes  under  early  observa- 
tion, a  more  or  less  marked  swelling  or  infiltration  of  the  skin 
in  various  parts  of  the  body  is  noted.  Sometimes  this  swelling 
is  very  marked.  Later  the  swelling  subsides,  the  skin  begins 
to  shrink,  and  a  feeling  of  stiffness  is  developed  in  the  skin, 
most  commonly  at  the  back  of  the  neck,  the  shoulders,  face, 


714  DISEASES    UF   THE   NERVOUS    SYSTEM. 

and  scalp.  The  disease  progresses  slowly,  and  at  the  height 
of  the  induration  the  skin  of  the  affected  area  becomes 
leather-like  in  thickness.  It  cannot  be  pinched  up,  nor  will  it 
pit  upon  pressure.  The  underlying  structures  become  fixed 
as  the  skin  becomes  rigid.  The  face  loses  all  expression ;  the 
movement  of  the  lower  jaw  is  very  limited.  If  the  skin  of  the 
chest  is  affected  respiration  is  interfered  with.  If  the  sclero- 
derma is  widespread  the  patient  lies  almost  as  rigid  as  a  statue. 
The  affected  skin  is  not  sharply  separated  from  the  sound 
skin ;  the  color  is  usually  white,  but  may  be  mottled  or  pig- 
mented.    The  mucous  membranes  may  be  affected. 

The  secretions  of  the  skin  are  diminished;  cyanosis  of  the 
limbs  is  common.  Deformities  result  late  in  the  disease. 
Shortening,  atrophy,  and  deformity  of  the  fingers,  with  thick- 
ening and  rigidity  of  the  skin,  give  rise  to  the  condition 
known  as  sclerodactylia.  In  morphea  the  patches  resemble 
the  diffuse  form,  but  the  rigidity  is  not  so  marked.  It  may 
be  complicated  by  Raynaud's  disease. 

The  outlook  is  best  in  children.  Spontaneous  recovery 
may  occur  in  the  early  stages.  The  disease  of  itself  is  not 
directly  fatal,  but  the  subjects  are  predisposed  to  intercurrent 
affections,  such  as  rheumatism  or  pneumonia. 

TREATMENT. 

The  patient  should  be  protected  from  cold  and  dampness. 
The  early  stages  are  the  most  favorable  for  the  employment 
of  salicylates,  and,  in  given  cases,  of  the  iodids  and  mercurials, 
and,  when  a  positive  Wassermann  is  present,  of  salvarsan. 
Thyroid  extract  has  been  used  with  apparent  benefit  in  some 
cases.  No  other  glandular  extracts  have  any  noticeable  effect. 
Galvanism  has  been  used  on  the  skin  near  the  affected  areas 
with  good  effect,  probably  by  the  production  of  hyperemia. 

The  patches  must  not  be  irritated  for  fear  of  ulceration  or 
possibly  further  thickening.  Massage  and  inunctions  of  oil 
are  beneficial.  Rubbing  must  be  gentle,  and  the  treatment 
kept  up  for  years.  Baths  are  of  service  only  in  so  far  as 
they  promote  general  nutrition.  Thiosinamin,  either  sub- 
cutaneously  or  by  mouth,  is  reported  of  value.  It  can  be  given 
in  capsules  of  0.05  gram  (gr,  ^)  at  a  dose. 


ACROPARESTHESIA.  715 

ERYTHROMELALGIA. 

This  affection  was  first  described  by  S.  Weir  Mitchell  in 
1872.  The  condition  is  a  rare  one,  most  commonly  affects 
men,  and  may  occur  at  any  age.  It  usually  attacks  the  feet, 
and  is  characterized  by  burning  pains  and  redness,  made  worse 
when  the  parts  are  allowed  to  hang.  As  in  Ra^maud's  disease, 
the  affection  appears  to  be  influenced  by  thermic  changes. 
Numbers  of  cases  are  reported  in  association  with  organic 
nervous  disease.     The  pathology  of  the  disease  is  obscure. 

The  characteristic  symptoms  of  erythromelalgia  relate  to 
pain  in  the  feet,  provoked  by  the  erect  posture  and  by  loco- 
motion. The  pain  may  be  intense,  and  is  described  as  aching 
and  burning.  The  affected  part  becomes  congested  and  swol- 
len and  has  the  appearance  of  an  active  hyperemia.  Profuse 
perspiration  may  occur.  In  the  beginning  the  attacks  are 
intermittent  and  brought  on  by  exposure  to  heat,  exertion,  or 
after  a  pendant  position.  Later  attacks  may  last  for  days  or 
weeks;  the  parts  become  cyanosed,  cold  and  often  thickened, 
with  trophic  affections  of  the  skin,  nails,  and  even  bones. 

The  differential  diagnosis  must  be  made  from  Raynaud's 
disease  and  the  pain  caused  by  flat-foot.  No  difficulties  are  as 
a  rule  presented. 

The  treatment  of  this  condition  is  most  unsatisfactory,  the 
outlook  as  to  cure  being  far  from  good.  The  patient  should 
avoid  overexertion  and  exposure  to  heat.  Rest  and  elevation 
of  the  part  help  in  relieving  the  pain.  Stretching  of  the  nerves 
supplying  the  parts  has  been  done  with  some  success.  Opium 
may  have  to  be  relied  upon  for  relief  of  pain  during  the  attack. 

ACROPARESTHESIA. 

This  affection  is  characterized  by  paresthesia  of  the  distal 
portions  of  the  extremities  and  is  one  of  the  most  common 
vasomotor  neuroses.  When  it  attacks  the  hands  and  feet  it 
may  arise  independently  of  all  other  diseases;  again,  it  may 
be  a  partial  phenomenon  of  various  neuroses. 

The  condition  is  commonest  in  the  female  sex.  usually 
after  middle  life,  and  in  those  who  do  scrul:)bing,  washing,  and 
sewing.     It  is  prone  to  occur  in  those  who  are  compelled  to 


716  DISEASES    OF   THE   NERVOUS    SYSTEM. 

be  on  their  feet  a  great  deal.  The  gouty  or  rheumatic  dia- 
theses and  alcoholism  appear  to  be  factors. 

The  condition  is  supposed  to  be  that  of  constriction  or 
spasm  in  the  peripheral  arteries  of  the  area  attacked.  Most 
cases  occur  in  persons  of  a  neuropathic  makeup. 

The  symptoms  include  pain,  numbness,  tingling  or  cold- 
ness, usually  beginning  in  the  hands,  and  later  affecting  the 
arms,  feet,  and  legs.  They  arise  suddenly,  in  the  morning 
before  the  patient  rises  from  his  bed.  The  numbness  is 
spoken  of  as  "waking  numbness."  Usually  there  is  no  mus- 
cular weakness  or  anesthesia.  General  restlessness  and  nerv- 
ousness generally  are  present.  Areas  of  local  congestion  and 
sweating  are  sometimes  seen.  The  parts  become  pale  in  the 
early  part  of  the  attack,  which  may  last  from  a  few  minutes 
to  several  hours,  and  later  there  is  a  reactive  hyperemia. 

TREATMENT. 

The  use  of  alcohol,  tea,  and  cofifee  should  be  discontinued. 
The  patient  should  avoid  occupations  in  which  there  is  irri- 
tation of  the  extremities  by  heat  and  cold.  The  diet  should 
be  plain  but  nutritious,  and  the  bowels  regulated.  Anemia 
can  be  treated  with  iron  and  arsenic.  The  dietary  should  be 
appropriately  regulated  in  gouty  and  rheumatic  subjects,  who 
also  should  undergo  a  course  of  anti-gouty  therapeusis. 
Bromids  may  be  of  value  in  vasomotor  irritability.  Electric- 
ity in  the  form  of  galvanism,  static  sparks,  or  high  frequency 
currents  may  help  the  pain  and  paresthesia.  Warm  salt  baths 
and  hot  air  baths,  followed  by  sponging  with  cold  water  and 
by  brisk  friction,  help  both  the  local  and  the  general  condi- 
tion. Various  drugs,  such  as  ergot  and  quinin,  are  thought 
to  be  of  benefit.  Cases  showing  signs  of  deficient  thyroid 
function  may  do  well  on  thyroid  extract. 

HYPERTROPHIC   PULMONARY    OSTEOAR- 
THROPATHY. 

This  disease,  described  by  Pierre  Marie,  is  characterized 
by  enlargement  of  the  hands  and  feet,  and  of  the  ends  of  the 
long  bones.  The  condition,  as  a  rule,  develops  slowly,  and 
is  always  associated  with  some  chronic  disease,  especially  of 


OSTEITIS    DEFORMANS   (FACET'S    DISEASE).  717 

the  lungs,  pleurae,  or  bronchi.  Some  cases  appear  to  follow 
syphilis,  and  others  heart  disease. 

The  characteristic  symptoms  of  the  disease  are  the  clubbed 
terminal  phalanges,  tipped  by  thickened,  curved,  and  deformed 
nails.  Thickening  of  the  lower  end  of  the  radius,  ulna,  or 
tibia,  may  be  marked,  and  at  times  these  structures  are  the 
seat  of  pain.  Changes  do  not  occur  in  the  bones  of  the  face 
or  head.     Effusion  into  the  joints  may  occur. 

The  course  of  the  disease  depends  upon  the  disease  pro- 
ducing it ;  it  does  not  of  itself  have  a  fatal  termination.  The 
treatment  is  that  of  the  primary  disease. 

LEONTIASIS    OSSEA. 

Leontiasis  ossea  is  a  rare  affection  in  which  there  is  hyper- 
ostosis of  the  cranial  bones.  There  is  greatly  increased 
thickening  of  the  cranium  and,  in  given  instances,  of  the  bones 
of  the  face.  It  occurs  early  in  life,  and  Putnam  regards  trauma 
as  a  factor  in  its  etiology.  The  pathology  of  the  affection  is 
not  understood. 

No  treatment  is  known.  Organic  extracts,  iodids,  arsenic, 
and  other  drugs  have  given  no  result.  As  a  rule,  the  process 
is  progressive.  Surgery  may  be  able  to  relieve  intracranial 
symptoms  due  to  pressure. 

OSTEITIS  DEFORMANS  (PAGET'S  DISEASE). 

This  disease,  prone  to  affect  men  of  middle  and  advanced 
age,  is  distinguished  by  certain  characteristic  features,  of 
which  a  large  head,  bowed  femurs  and  tibiae,  and  thick  clav- 
icles are  the  most  significant. 

The  patient  may  first  notice  his  symptoms  by  the  gradual 
increase  in  the  size  of  his  head,  or  because  of  a  decrease  of 
his  height.  When  fully  developed  the  large  skull  is  noticed 
in  contrast  to  the  narrow  face.  The  expression  is  often  dull, 
and  the  patients  look  older  than  their  years.  Ankylosis  of 
the  vertebrae  or  other  joints  is  not  uncommon.  The  hips  are 
wide,  the  femurs  curved  outward,  and  the  tibiae  thick  and 
curved.  The  disease  lasts  for  years.  The  cause  is  unknown. 
Marked  arteriosclerosis  is  constantly  present. 


718  DISEASES    OF   THE   NERVOUS    SYSTEM. 

The  treatment  is  purely  symptomatic.  Various  organic 
extracts  have  been  used  vv^ith  little  or  no  effect.  A  case  at 
present  under  observation  seems  to  have  done  well  for  the 
past  year  on  adrenalin.  The  treatment  is  practically  limited 
to  keepi-ng  the  patient  in  the  best  physical  condition  and  ward- 
ing off,  if  possible,  arteriosclerotic  changes. 

ADIPOSIS    DOLOROSA. 

This  affection,  described  by  Dercum,  is  a  disease  of  adult 
life.  It  is  characterized  by  deposits  of  fat  in  various  parts  of 
the  body,  the  deposits  being  painful  and  tender  to  touch  and 
pressure.  They  occur  especially  upon  the  arms,  hips,  chest, 
abdomen  and  back;  but  also  upon  the  forearms,  about  the 
knees,  and  less  frequently  the  legs.  They  never  occur  on  the 
hands  and  feet,  and  are  extremely  rare  upon  the  face ;  one 
case  with  deposits  upon  the  forehead  has  been  observed  by 
one  of  the  writers.  Most  frequently  they  present  themselves 
in  the  form  of  separate  masses  or  nodules.  Less  frequently,  in 
the  form  of  diffuse  localized  deposits,  and  least  frequently  in 
the  form  of  a  diffuse  generalized  adiposis.  The  nodules  are 
composed  of  fat,  and  the  pain  and  tenderness  are  accounted 
for  by  a  localized  neuritis  in  the  fatty  tissue.  The  nodules  or 
masses  sometimes  make  their  appearance  quite  rapidly,  the 
swelling  being  very  painful,  and  for  a  time  even  indurated  and 
hard  like  a  "caked  breast" ;  the  induration  later  subsides, 
but  the  enlargement  persists.  Most  frequently  the  deposits 
make  their  appearance  gradually.  There  is  muscular, 
-and  often  cardiac,  weakness.  Spontaneous  bleeding  may 
occur  from  the  mucous  surfaces  and  occasionally  into  the 
fatty  tissue ;  the  latter  bruises  very  readily.  There  are  no 
sensory  changes,  save  a  slight  occasional  diminution  of  cuta- 
neous sensibility  in  the  affected  areas.  There  are  no  char- 
acteristic changes  in  the  reflexes.  Mental  changes  are  not 
noted,  save  in  long-standing  and  advanced  cases.  Hebetude 
and  mental  slowness  may  then  be  noted,  or,  on  the  other  hand, 
marked  irritability,  suspicion,  confusion,  and  even  halluci- 
nations. A  few  cases  have  necessitated  asylum  commitment. 
On  the  whole,  however,  mental  symptoms  are  infrequent. 


ADIPOSIS    DOLOROSA.  719 

In  cases  that  are  at  all  pronounced  the  prognosis  is  very 
unfavorable,  the  patient  finally  dying-  of  cardiac  weakness  and 
general  exhaustion.  Autopsies  have  demonstrated  atrophic 
and  other  changes  in  the  thyroid  gland,  and,  in  varying  de- 
grees, in  the  pituitary  and  adrenals.  Adiposis  dolorosa  is 
clearly  a  disease  of  the  internal  secretions. 

The  symptoms  are  quite  characteristic.  The  only  cases 
presenting  difificulty  are  those  in  which  the  nodules  are  very 
small.  Here  a  careful  examination  usually  resolves  the  doubt. 
The  afifection  is  readily  distinguished  from  myxedema  by  the 
fact  that  in  the  latter  the  head  and  face  are  early  implicated, 
and  by  the  absence  of  pain. 

Early  cases  are  greatly  benefited  by  treatment  with  thyroid 
extract,  and,  at  times,  the  affection  is  permanently  arrested 
by  this  means.  In  severe  and  pronounced  cases,  however, 
thyroid  administration  fails,  and  the  patient  goes  from  bad  to 
worse.  Strict  dietary  measures  should,  of  course,  be  insti- 
tuted. The  pain  should  be  controlled  by  the  salicylates  and 
iodids;  the  cardiac  and  general  weakness,  by  appropriate 
measures.    When  the  pain  permits,  massage  maj^  be  practised. 


INDEX. 


Abulia,  604 
Abscess,  filarial,  387 

of  brain,  655 
Acetone,  519 
Acid,  diacetic,  519 

intoxication,  518,  520,  525 

determination  of  degree  of,  519 
differentiated  from  uremia,  521 
Acidosis.     See  Acid  Intoxication. 
Acquired  hydrocephalus,  655 
Acroparesthesia,  715 
etiology,  715 
pathology,  716 
symptoms,  716 
treatment,  716 
Actinomycosis,  126 
cerebral,   127 
miliary,  127 
pulmonary,    127 
treatment,   127 
Acute  anterior  poliomyelitis.  111,  670 
etiology,  111.  670 
pathology,  670 
prognosis,  671 
symptoms,  671 
treatment,  672 
types,   112 
bulbar  paralysis,  673 
etiology,  673 
symptoms,  674 
cerebral  leptomeningitis,  653 
diagnosis,  654 
etiology,  653 
pathology,  653 
symptoms,  653 
treatment,  654 
myelitis,  679 
etiology,  679 
symptoms,  680 
treatment,  680 
Addison's  keloid,  713 
Adenitis  in  diphtheria,  65 
in  scarlet  fever,  177 
tuberculous,  71 
Adiposis  dolorosa,  478,  718 
prognosis,  719 
symptoms,  719 
treatment,  719 
Adolescent  rickets,  476 
Affusion,  cold,  13 
Agar  and  bran  biscuits,  537 
Ague,  205 


46 


Air,    carbon    dioxid   tension    of    al- 
veolar, 518,  521 
Albuminuria   in   scarlet    fever,    174 
Alcohol,  caloric  value  of,  457 

in  pneumonia,  Zl 

in  typhoid   fever,   16 

methyl,  poisoning,  442 

poisoning,   438 
methyl,  442 

wood,  poisoning,  442 
Alcoholism,  438 

treatment  of  acute,  438 
of  chronic,  438 
of  delirium  tremens,  440 
Algid  type  of  malaria,  223 
Alimentary  glycosuria,  515 

obesity,  477 
Alveolar  air,  carbon  dioxid  tension 

of,  518,  521 
Ameba  histolytica,  306 
American  pest,  239 
Amino-acids,  452 
Amyotrophic  lateral  sclerosis,  676 

etiology,  676 

pathology,  676 

symptoms,  676 

treatment,  676 
Anaphylaxis,  57 

Ancylostoma    duodenale,    289,    292, 
294 

technique  for  finding,  298 
Anemia,  cerebral,  657 
etiology,  658 
symptoms,  658 
treatment,  658 

headache  in,  611 
Anesthetic  leprosy,  188,  199 
Angina,  treatment  of  scarlatinal,  172 
Angioneurotic    edema,    710 

pathology,  711 

symptoms,  710 

treatment,  711 
Anopheles,  209,  210,  216,  219,  237 
Anorexia    nervosa,    treatment,    596, 

598 
Anterior  poliomyelitis,  111,  670 

etiology.  111.  670 

pathology,  670 

prognosis,  671 

symptoms,  671  « 

treatment,  672 

tvpes,  112 

(721) 


722 


INDEX. 


Anthrax,  102 

erysipelatous,  102 
external,  102 
internal,  102 
prophylaxis,  104 
synonyms,  102 
treatment,  103 
Antimeningococcic  serum,  97,  654 
Antiseptics,     intestinal,     in    typhoid 

fever,  16 
Antitetanic  serum,  99 
Antityphoid  vaccination.  7 
Apoplexy  (cerebral),  659 
etiology,  659 
pathology,  660 
symptoms,  660 
treatment,  661 
Appendicitis  in  typhoid  fever,  25 
Apthse,  tropical,  344 
Arachnidia,  140 
Argyria,  426 

treatment,  427 
Arsenic  in  arthritis,  553 
in  diabetes,  535 
poisoning,  418 
acute,  418 
chronic,  420 
subacute,  419 

(See      also      "Poisoning,      Ar- 
senic") 
Arthritis,  541 

Barker's  classification  of,  541 
chronic,  of  spine,  568 
chronic  villous,  568 
congenital,  541 
deformans,  116,  567 

differentiated  from  gout,  503 
gonococcal,  88,  89,  550 
infectious,  543 
arsenic  in,  553 
aspirin  in,  553 
baking  in,  556 
determination  of  primary  focus 

in,  545,  ct  seq. 
elimination  in,  555 
etiology,  544 

flat-foot  as  factor  in,  558 
iodids  in,  554 
massage  in,  556,  557 
passive  motion  in,  556 
pathology,  544 
rest  in,  557 
salicylates  in,  554 
symptoms,  543 
thymus  gland  in,  555 
thyroid  extract  in,  554 
treatment,  545 
by    intravenous    injection    of 
foreign  proteins,  553 


Arthritis,  treatment, 
climatic,  559 
local,  556,  558 
medical,  553 
vaccines  in,  551 

;ir-ray  in  finding  primary  focus, 
546 
inflammatory,  541,  542 

clinical  classification  of,  542 
in  pneumonia,  40 
in  scarlet  fever,  175 
multiple  secondary,  116 
neuritis  accompanying,  570 
neuropathic,  541 
treatment,  542 
of  spine,  568 
primary  hypertrophic  osteo-,  543 

treatment,  545 
primary  progressive  poly-,  559 
caloric  feeding  in,  561 
codliver  oil  in,  567 
diagnosis,  559 
dry  form,  561 
pathology,  559 
radium  in,  559 
symptoms,  559 
treatment,  561 
dietetic,  563 
rheumatoid,  567 
sacroiliac,  558 
uratica,  496 
Arthropathies,  chronic,  of  spine,  568 
Ascariasis,  136 
symptoms,  136 

treatment,  137  » 

Ascaris  lumbricoides,  136 
Ascending    spinal    paralysis,    acute, 

683 
Asiatic  cholera,  256 
Asphyxia,  pestilential,  256 
Aspirin  in  arthritis,  554 

in  migraine,  614 
Astasia  abasia,  591 

treatment,  596 
Ataxia,  hereditary,  677 
pathology,  677 
symptoms,  677 
treatment,  677 
types,  677 
hereditary  cerebellar,  677 
Ataxic  paraplegia,  676 
etiology,  676 
pathology,  676 
symptoms,  677 
treatment,  677 
Atophan  in  gout,  511 
Atrophy,  progressive  muscular,  674 
diagnosis,  675 
etiology,  674 


INDEX. 


723 


Atrophy,  progressive  muscular. 

pathology,  674 

symptoms,  674 

treatment,  675 
progressive  neuritic  muscular,  686 

etiology,  686 

pathology,  686 

prognosis,  687 

symptoms,  686 

treatment,  687 
Aura,  epileptic,  618 
Autogenous  vaccines,  SO,  51,  551 

Bacillary  dysentery,  315.     See  Dys- 
entery. 
Bacillus  anthracis,  102 

Bordet-Gengou,   104 

choleras  suis,  240 

colon,  infections  by,  50 

dysenterica,  315,  317 

Eberth's,  3 

icteroides,  240 

influenza,  89 

Klebs-Loffler,  51 

lactimorbi,  146 

lepra;,  187,  191,  194 

mallei,  101 

pertussis,  104 

pestis,  366,  368 

Pfeiffer's,  89 

tetanus,  98 

typhosus,  3 
Bacterial  dysentery,  314 

chronic,  321 
Bagdad  boil,  342 
Baking  in  arthritis,  556 
Balantidic  dysentery,  304 
Balantidium  coli,  304 
Barany  tests,  616 
Barker's  classification  of  arthritides, 

541 
Barlow's  disease,  468.     See  Scurvy, 

Infantile. 
Bath,  Brand,  12 

contraindications  to,  13 

sponge,  14 
Baths  in  obesity,  495 
Bed-bug,  143 
Bed-linen,  disinfection  of  in  typhoid 

fever,  5 
Beef  tapeworm,  130 
Bell's  palsy,  701 

diagnosis,  702 

etiology,  701 

symptoms,  701 

treatment,  702 
Benedict's  solution,  529 
Benign  type  of  malaria,  213 
Beriberi,  273 


Beriberi,  diagnosis,  280 

distribution,  275 

dry,  277,  279 

etiology,  275,  456 

history,  274 

incubation  period,  278 

infantile,  285 

low-grade,  285 

mortality,  281 

pathology,  277 

prophylaxis,  283 

rice  extract  in,  281 

sequelae,  280 

ship,  468 

symptoms,  278 

synonyms,  273 

treatment,  281 

wet,  277,  279 
Bilharziasis,  129 
Biscuits,  bran  and  agar,  537 
Black  death,  366 
Bladder,  tuberculosis  of,  75 
Bleeder's  joint,  541 
"Blue  line"  on  gums,  421 
Bodies,  purin,  500 
Body,  crescent,  208,  209,  210 

flagellated,  207 

Leishman-Donovan,  353,  354 
Boil,  Bagdad,  342 

Delhi,  342 

yearly,  342 
Bordet-Gengou  bacillus,  104 
Brachial  plexus,  neuralgia,  704 
treatment,  705 

neuritis,  704 
treatment,  704 

paralysis,  703 
treatment,  704 
Brain  abscess,  655 
diagnosis,  656 
symptoms,  656 
treatment,  656 

diseases  of,  651 

tumor,  662 
diagnosis,  663 
pathology,  662 
symptoms,  663 
treatment,  663 
types,  662 
Bran  and  agar  biscuits,  537 
Brand  bath.  12 

contraindications,  13 
Breakbone  fever,  247 
Breakheart  fever,  247 
Bromides  in  migraine,  614 
Bronchial  adenitis,  tubercular.  12 
Bronchitis  in  typhoid   fever,  21 
Broncho-pneumonia,  43 

in  diphtheria,  64 


724 


INDEX. 


Bruce's  septicemia,  250 

Bubas,  332 

Bubonic  plague,  366,  375 

destruction  of  rats  in,  380 

diagnosis,  2)11 

differential  diagnosis,  Zll 

distribution,  367 

etiolog}',  368 

history,  366 

incubation,  375 

mortality,  378 

pathology,  374 

pneumonic  type,  Zll 

prophylaxis,  379 

septicemic  type,  376 

synonyms,  366 

transmission,  368 

treatment,  378 

types,  375 
Bulbar  palsy,  acute,  673 
etiology,  673 
symptoms,  674 

chronic  progressive,  675 
symptoms,  675 
treatment,  675 

Cachectic  fever,  352 

Caloric  feeding  in  arthritis,  561 

value  of  alcohol,  457 
of  carbohydrates,  453 
of  foods,  460 
of  hydrocarbons,  452 

of  proteins,  451 
Calories,  definition,  457 

daily  number  required,  458 
Calorimeter,  457 

Cannabis  indica  in  migraine,  614 
Carbohydrates,  453 

caloric  value,  453 

composition,  453 

respiratory  quotient  for,  457 
Carbon   dioxid   tension    of   alveolar 
air,  518,  521 

monoxid  poisoning,  427 
Cardiac   failure   in   diphtheria,  63 

weakness  in  typhoid  fever,  22 
Carriers  of  dysentery,  311 

of  infection,  153 
Catarrhal  pneumonia,  43 
Cells,  Langhans',  195 

lepra,  195 
Central   facial  palsy,  701 

myelitis,  679,  680 
Centrally  acting  emetics,  413 
Cerebellar  ataxia,  hereditary,  677 
Cerebral  actinomycosis,  127 

anemia,  657 
etiology,  658 
symptoms,  658 


Cerebral  anemia, 
treatment,  658 
apoplexy,  659 
etiology,  659 
pathology,  660 
symptoms,  660 
treatment,  66^ 
hyperemia,  658 
etiology,  658 
symptoms,  659 
treatment,  659 
rheumatism,  115 
sinus  thrombosis,  657 
Cerebrospinal  fever,  95 
symptoms,  95 
transmission,  95 
treatment,  96 
syphilis,  84 
subarachnoid  injections  in,  84 
Cervical  pachymeningitis,  664 

tubercular  adenitis,  12 
Cestodes,  130.     See  Tapeworm. 
Ceylon  sore  mouth,  344 
Chagres  fever,  205 
Chaulmoogra  oil,  203 
Chenopodium    in    hookworm    infec- 
tion, 300 
Chicken-pox,  162.     See  Varicella. 
Chills  and  fever,  205 
Cholecvstitis  in  typhoid  fever,  24 
Cholera,  256 
ambulant,  268 
asiatica,  256 
complications,  269 
diagnosis,  266,  269 
distribution,  256 
etiology,  261 
history,  256 
incubation,  267 
mortality,  269 
pathology,  264 
prognosis,  269 
prophylaxis,  270 
sicca,  269 
spirillum  of,  265 
symptoms,  267 
synonyms^  256 
transmission,  259,  262 
treatment,  270 
varieties,  268 
Cholerine,  268 
Chorea,  626 

and  rheumatism,  114,  115 
electric,  630 
prognosis,  630 
symptoms,  630 
forms  of,  626 
habit,  632 
treatment,  632 


INDEX. 


725 


Chorea,  Huntingdon's,  628 
age  incidence,  628 
etiology,  629 
pathology,  629 
prognosis,  629 
symptoms,  629 
treatment,  630 
minor,  626 
of  childhood,  626 
Sydenham's,  626 
age  incidence,  626 
prognosis,  627 
symptoms,  627 
treatment,  628 
Chronic  malaria,  217,  225 
myelitis,  679 
etiology,  682 
pathology,  682 
symptoms,  682 
treatment,  682 
progressive  bulbar  palsy,  675 
symptoms,  675 
treatment,  675 
Chvostek's  symptom,  645 
Chylous  diarrhea,  390 

dropsy,  389 
Chyluria,  387 

treatment,  388 
Cimex  lectularis,  143 
Claudication,  intermittent,  711 
Coast  fever,  205 
Coccygodynia,  708 

treatment,  708 
Cocainism,  430 
treatment,  431 
Cochin  China  diarrhea,  344 
Codliver  oil  in  arthritis,  567 
Colchicum  in  gout,  511 
Cold  affusion,  13 
Colds,  infectious,  148 
etiology,   148 
symptoms,  148 
treatment,  149 
Colic,  lead,  421,  423 
Colon  abnormalities  in  arthritis,  549 

bacillus  infections,  50 
Colostomy  in  arthritis,  549 
Coma,  treatment  of  diabetic,  535 
Combined  system  diseases  of  spinal 

cord,  676 
Compression  myelitis,  681 
etiology,  681 
pathology,  681 
symptoms,  681 
treatment,  681 
Concussion  of  spine,  600 
Congenital  hydrocephalus,  655 
rickets,  476 
syphilis,  76,  n,  85 


Contagious  diseases,  153 
Convulsions,  hysterical,  593 
infantile,  622 

etiology,  623 

sequels,  623 

symptoms,  624 

treatment,  624 
puerperal,  625 

treatment,  626 
Copper  poisoning,  425 
symptoms,  425 
treatment,  425 
Cranial  nerves,  diseases  of,  699 
Crescent  bodies,  208,  209,  210 
Cretinism,  486 
Crises,  hysterical,  593 
Crisis  of  pneumonia,  41 
Croupous  pneumonia,  27 
Culex  fatigans,  247 
Cyprus  fever,  250 
Cystitis  in  typhoid  fever,  23 

Dance,  St.  Vitus',  626 
Death,  black,  366 
Delhi  boil,  342 
Delirium  in  pneumonia,  35 
in  tj^phoid  fever,  23 
tremens,  treatment,  440 
Dengue,  247 
diagnosis,  249 
differential  diagnosis,  249 
history,  247 
incubation,  248 
mortality,  250 
prophylaxis,  250 
symptoms,  248 
synonyms,  247 
transmission,  247 
treatment,  250 
Dercum's  disease,  478 
Dermacentor  occidentalis,  108 
Diabetes,  515 
insipidus,  537 
diagnosis,  539 
iodiopathic,  538 
prognosis,  539 
symptomatic.  538 
symptoms,  538 
treatment,  539 
varieties,  538 
mellitus,  515 

acid    intoxication    in,    518,    519, 

520.  521..  525 
arsenic  in,  535 
complications.  520,  521 

treatment,  536 
course,  519 

determination      of      de.grcc      of 
acidosis  in,  519 


726 


INDEX. 


Diabetes    mellitus,    diet    in,    525,    ei 
seq. 
drug  treatment,  534 
duration,  520 
etiology-,  516 
exercise  in,  534 
"green  days"  in,  524,  528 
in  children,  519 
Janeway's  dietary,  526 
opium  in,  534 
pathology,  517 
predisposing  causes,  515 
respiratory  quotient  in,  518 
symptoms,  520,  521 
treatment,  523 
of  coma,  535 
of  complications,  536 
phloridzin,  515 
renal,  515 
Diabetic  coma,  treatment,  535 
Diacetic  acid,  519 

Diarrhea    and    dysentery    differen- 
tiated, 304 
choleraic,  268 
chylous,  390 
Cochin  China,  344 
in  influenza,  93 
in  typhoid  fever,  15 
lymph,  390 
tropical,  344 
Diathesis,  uric  acid,  497 
Diathetic  headache,  609 
Diet  in  arthritis,  563,  565 
in  gout,  505 

in  neurasthenia,  583,  585 
in  obesity,  488,  493 
oatmeal,  525 
Saulsbury,  507 
Dietary,  antiscorbutic,  466 
Diffuse  myelitis,  679 

spinal  cord  diseases,  678 
Digitalis  in  pneumonia,  41 
Dilatation    of    stomach    in    typhoid 

fever,  20 
Diplococcus     intracellularis    menin- 
gitidis, 95 
Diphtheria,  51 
adenitis  in,  65 
antitoxin,  54 

complications  of  use,  57 
dosage,  55,  58 
bronchopneumonia  in,  64 
cardiac  failure  in,  63 
complications,  53,  63 

treatment,  63,  64 
diagnosis,  S3 
differential  diagnosis,  53 
extubation  in,  61 
intubation  in,  60 


Diphtheria,  laryngeal,  56 
treatment,  59 
nasal,  56 
nephritis  in,  65 
paralysis  following,  64 
pathology,  52 
prophylaxis,  58 
symptoms,  53 
tonsillar,  56 
tracheotomy  in,  62 
transmission,  52 
treatment,  54 
Disease,  Barlow's,  468 
Dercum's,  478 
echinococcus,  135 
foot-and-mouth,  147 
Friedreich's,  677 
Little's,  668 
Paget's,  718 
symptoms,  718 
treatment,  719 
Parkinson's,  647 
Quincke's,  710 
Raynaud's,  708 
etiology,  709 
symptoms,  708 
treatment,  709 
Still's,  569 
pathology,  569 
treatment,  569 
tick,  141 
Weil's,  125 
Diseases,  contagious,  153 

of  brain  and  its  membranes,  651 
of  special  nerves,  699 
of  spinal  cord,  666 
combined  system,  676 
dift'use,  678 

lower  motor  neuron,  670 
upper  motor  neuron,  667 
Distomiasis,  hemic,  129 
hepatic,  128 
intestinal,   129 
pulmonary,  128 
Dizziness,  615 
Double  quartan  fever,  221 
subtertian  fever,  223 
tertian  fever,  222 
Douches  in  hysteria,  595 
D:N  ratio,  518 
Dropsy,  chylous,  389 

sleeping,  286 
Dry  beriberi,  277,  279 

form  of  arthritis,  561 
Dumdum  fever,  352 
Dysentery,  303 
amebic,  306 

carriers  of,  311 
complications,  311 


INDEX. 


727 


Dysentery,  amebic,  diagnosis,  311 

distribution,  307 

etiology,  306,  307 

history,  306 

pathology,  309 

prognosis,  312 

prophylaxis,  313 

symptoms,  310 

transmission,  308 

treatment,  312 
bacterial,  314 

chronic,  321 
bacillary,  315 

complications,  322 

differential  diagnosis,  322 

distribution,  316 

etiology,  317 

history,  315 

incubation,  320 

infantile,  322 

mortality,  322 

pathology,  318 

prophylaxis,  324 

symptoms,  319 

transmission,  317 

treatment,  323 
balantidic,  304 

etiolog3^  304,  305 

treatment,  305 
differentiated   from   diarrhea,  304 
due  to  animal  parasites,  303 
due  to  bacteria,  304 
entero-,  321 
gangrenous,  321 
infantile,  322 
protozoal,  304 
Dystrophies,  muscular,  685 
etiology,  685 
pathology,  685 
prognosis,  686 
symptoms,  685 
treatment,  686 
types,  685 
Eberth's  bacillus,  3 
Echinococcus  disease,  135 

treatment,  135 
Eczema  and  gout.  503 
Edema,  acute  circumscribed,  710 
angioneurotic,  710 

pathology.  711 

symptoms,  710 

treatment,  711 
malignant,  102 
Effusion,  tubercular  pleural.  74 
Electric  light  bath  in  gout,  510 
Electricity  in  hysteria,  595 
in  neurasthenia,  584,  585 
Elephantiasis,  391 
pf  legs,  394 


Elephantiasis  of  legs, 
treatment,  394 

of  scrotum,  395 
treatment,  395 

of  vulva,  395 
treatment,  396 

pathology,  393 

symptoms,  393 

synonyms,  392 
Embolism  of  spinal  cord,  679 
Emetics,  centrally  acting,  413 

locally  acting,  413 
Emetin  hydrochlorid,  546 
Empyema  in  pneumonia,  39 
Endemic  polyneuritis,  273 
Endocarditis,  gonorrheal,  89 

in  typhoid  fever,  22 

rheumatic,   114 
Endogenous  obesity,  478 

purin  bodies,  500 
Entameba  buccalis,  546 

coli,  307 

histolytica,  307 

tetragena,  308 
Enterodysentery,  321 
Ephemeral  fever,  124 
Epidemic  meningitis,  95 

parotitis.  110 

remittent  fever,  329 
Epilepsy.  618 

aura  in,  618 

etiology,  619,  620 

pathology,  620 

symptoms,  619 
premonitory,  618 

traumatic,  620 

treatment,  621 
Epiphysitis,   117 
Erb's  symptom,  645 
Erysipelas,  65 

etiolog}',  65 

facial,  66 

following  vaccination,  162 

symptoms,  66 

transmissibility,  66 

treatment,  67 
Erysipelatous  anthrax.  102 
Erythema  in  rheumatism,  115 

nodosa,  115 
Erythromelalgia,  715 

symptoms,  715 

treatment,  715 
Exanthemata.  153 
Exercise  in  diabetes,  534 

in  neurasthenia,  5S7 

in  obesity,  495 
Exhaustion,  heat.  444 

nervous.  578 
Exogenous  obesity,  478 


728 


INDEX. 


Exogenous  obesity. 

purin  bodies,  500 
External  anthrax,  102 

cerebral  pachymeningitis,  651 

hydrocephalus,  655 
Extubation,  61 

Exudative   form   of   nerve   syphilis, 
687 

Facial  erysipelas,  66 

hemiatrophy,  progressive,  712 
myospasms,  633 
treatment,  634 
paralysis,  701 
central,  701 
diagnosis,  702 
etiology,  701 
peripheral,  701 
symptoms,  701 
treatment,  702 
Familial  tremors,  650 
Fatigue  neurosis,  578 
Fats  as  hydrocarbons,  452 
Febricula,  124 

treatment,  124 
Feces  disinfection   in  typhoid,  4 
Fever,  breakbone,  247 
breakheart,  247 
cachectic,  352 

cerebrospinal,   95.      See    Cerebro- 
spinal Fever. 
Chagres,  205 
chills  and,  205 
coast,  205 
Cyprus,  250 
dumdum,  352 
ephemeral,  124 
epidemic  remittent,  329 
five-day,  329 
girafife,  247 
glandular,   126 
intermittent,  205 
Malta,  250.     See  Malta  Fever, 
marsh,  205 
Mediterranean,  250 
miliary,  149 
Neapolitan,  250 
para-Malta,  254 
paratyphoid,  27 
quartan,  213,  219 
double,  221 
simple,  220 
triple,  221 
rat-bite,  325.     See  Rat-bite  Fever, 
relapsing,     328.       See     Relapsing 

Fever, 
remittent,  205,  329 
rheumatic,  113 
Rocky  Mountain  spotted,  108 


Fever,  seven  days',  247 

spirillum,  329 

splenic,  102 

spotted,  95 

subtertian,  222 

tertian,  213,  219,  221 
double,  222 
simple,  221 

thermic,  444 

typhoid,  3.     See  Typhoid  Fever. 

typhus,  359.     See  Typhus  Fever. 

undulant,  250 

yellow,  239.     See  Yellow  Fever. 
Fibrositis,  544,  567 
Fifth    cranial    nerve,    neuralgia    of, 
700 
treatment,  700 

paralysis,  700 
Filaria,  383,  396 
Filarial  lymphangitis,  390 

treatment,  391 
Filariasis,  382 

abscess  in,  387 

clinical  types,  387 

distribution,  383 

edema  in,  384 

elephantiasis  from,  391.    See  Ele- 
phantiasis. 

etiology,  383 

history,  382 

lymphatic  varix  in,  384 

mortality,  397 

prognosis,  397 

prophylaxis,  397 

sequelse,  397 
Fish  tapeworm,  130 
Five-day  fever,  329 
Fixation  test,  gonorrheal,  87 
Flagellated  body,  207 
Flat-foot  as  cause  of  arthritis,  558 
Flea,  common,  143 

sand,  143 
Flexner's  serum,  97,  654 
Flies,  parasitic,  144 
Focal  symptoms  of  brain  tumor,  663 
Folie  du  doute,  604 
Food  poisoning,  443 
prophylaxis,  443 
treatment,  443 
Foods,  caloric  value  of,  460 
Foot-and-mouth  disease,  147 

treatment,  14S 
Forms,  crescentic,  208,  209,  210 
P>ambesia,  332 

diagnosis,  340 

from  syphilis,  34Q 

distribution,  334 

etiology,  334 

history,  333 


INDEX. 


729 


Frambesia,  incubation,  337 

prognosis,  341 

prophylaxis,  342 

stages,  337 

symptoms,  337 

synonyms,  332 

transmission,  335 

treatment,  341 
Friedreich's  disease,  677 

myoclonus  multinlex,  640 
Fright  hysteria,  602 
Frohlich's  syndrome,  478 
Fumigation,  169 
Functional  headaches,  608 

nervous  diseases,  577 

tremors,  649 
Furunculosis  in  typhoid  fever,  24 

Gangrene,  symmetrical,  709 
Gangrenous  dysentery,  321 
Gastro-intestinal  hypochondria,  607 
Genito-urinary  tuberculosis,  75 
German  measles,  183 

diagnosis,  184 

incubation,  183 

symptoms,  183 

treatment,  184 
Giant  urticaria,  710 
Giddiness,  615 
Girafife  fever,  247 
Glanders,  101 

chronic,  101 

diagnosis,  101 

etiology,  101 

treatment,  101 
Glandular  fever,  126 
Glossina  morsitans,  286 

palpalis,  286 
Glucose,  amount  in  blood,  517 
Glycogen,  storage  of,  517 
Glycosuria,  515 

alimentary,  515 

ex  amyli,  515 
Gonococcus  infection,  86 

diagnosis,  86 

treatment,  88 
Gonorrheal  arthritis,  88,  89,  550 

endocarditis,  89 

fixation  test,  87 

ophthalmia,  87 

septicemia,  87,  89 

serums,  89 

vaccines,  89 

vaginitis,  87 
Gout,  496 

acute,  501 

recurrence  of,  501 
symptoms,  501 
treatment,  512 


Gout,  acute. 

associated  conditions,  502 
chronic,  502 
symptoms,  502 
treatment,  514 
diet,  505 
differential  diagnosis,  503 

from  arthritis  deformans,  503 
from  Heberden's  nodes,  503 
from  rheumatism,  117,  503 
electric  light  bath  in,  510 
hereditary,  501 
irregular,  502 

treatment,  514 
polyarticular,  502 
pathology,  499 
predisposing  causes,  498 
prognosis,  502 
retrocedent.  504 
treatment,   504 
climatic,  509 
dietetic,  505 
hygienic,  508 
medicinal,  511 
uric  acid  in,  499 
uricemia  in,  500 
urine  in,  500 
Gouty  sore  throat,  treatment,  514 
Grand  mal,  618 
"Green    days"    in    diabetic    feeding, 

524,  528 
Growing  pains,  115 

Habit  chorea,  632 
treatment,  632 

cocain,  430 

morphin,  434 

spasm,  632 
treatment,  632 
Havana,  pest  of,  239 
Headache,  608 

diathetic,  609 

from     affections     of     organs     of 
soecial  sense,  610 

from  anemia,  611 

from   circulatory    disturbances   in 
brain,  611 

from  infections,  610 

from  sinusitis,  611 

functional,  608 
types,  608 

hysteric,  609 

neurasthenic,  608 

organic    608 

toxic,  610 

uremic,  609 
Heat  exhaustion,  444 

prophylaxis,  444 

treatment,  44^ 


730 


INDEX. 


Heberden's  nodes,  569 

differentiated  from  gout,  503 
pathology,  570 
Helminthiasis,  127 
Hematomyelia,  678 
Hemaforrhachis,  678 
Hemiatrophy,  progressive  facial,  712 
etiology,  712 
pathology,  713 
symptoms,  712 
treatment,  713 
Hemic  distomiasis,  129 
Hemorrhage  in  typhoid  fever,  19 
spinal  meningeal,  678 
etiology,  678 
symptoms,  678 
treatment,  679 
Hemorrhagic  malaria,  224 

pachymeningitis,  652 
Hemozoin,  206 
Hepatic  distomiasis,  128 
Hereditary  ataxia,  677 
pathology,  677 
symptoms,  677 
treatment,  677 
tvpes,  677 
cerebellar  ataxia,  677 
gout,  501 

spastic  paraplegia,  667 
etiology.  667 
prognosis,  668 
symptoms,  668 
treatment,  668 
tremors,  650 
Herpes  and  dorsal  neuritis,  705 
Hoffman's  symptom,  646 
Hookworm  infection,  289 
diagnosis,  297 
distribution,  291 
etiology,  289,  292 
history,  289 
pathology,  293 
prophylaxis,  301 
symptoms,  296 
treatment,  299 
Hydrocarbons,  452 
caloric  value,  452 
composition,  452 
respiratory  quotient  for,  457 
Hydrocephalus,  655 
acquired,  655 
congenital,  655 
external,  655 
internal,  655 
types,  655 
symptoms,  655 
treatment,  655 
Hydrophobia,  144 
Hydrotherapy  in  obesity,  494 


Hyperemia,  cerebral,  658 
etiology,  658 
symptoms,  659 
treatment,  659 
Hyperglycemia,  518 
Hypertrophic   cervical  pachymenin- 
gitis, 664 

etiology,  664 

pathology,  665 

symptoms,  664 

treatment,  665 
leprosy,  188,  197 
pulmonary   osteoarthropathy,   716 

symptoms,  717 
Hypochondria,  606 
definition,  606 
gastro-intestinal  form,  607 
incidence,  606 
prognosis,  607 
sexual  form,  607 
treatment,  607 
Hypothyroidism    in    psychasthenia, 

605 
Huntingdon's  chorea,  628 
age  incidence,  628 
etiology,  629 
pathology,  629 
prognosis,  629 
symptoms,  629 
treatment,  630 
Hysteria,  589 
astasia  abasia  in,  591 

treatment,  596 
convulsions  in,  593 
definition,  589 
douches  in,  595 
electricity  in,  595 
fright,  602 
headache  in,  609 
history,  589 
insomnia  in,  599 
litigation,_  602,  603 
massage  in,  595 
phantom  tumor  in,  592 
psychotherapy  in,  599 
rest  in,  594 
symptoms,  589,  590 

motor,  591 

psychic,  593 

sensory,  590 

somatic,  592 
traumatic,  600 
treatment,  594 

of  anorexia,  596,  598 

of  contractures,  596 

of  nausea,  596 

of  palsies,  596 

of  vomiting,  596 

symptomatic,  596 


INDEX. 


731 


Hysterical  convulsions,  593 

crises,  593 
Hystero-neurasthenia,  traumatic,  601 

Idiopathic  diabetes  insipidus,  538 

tremors,  650 
Ileocolostomy  in  arthritis,  549 
Illuminating  gas  poisoning,  427 
acute,  pathology,  428 
sequelae,  429 
symptoms,  429 
treatment,  430 
ch   jnic,  pathology,  428 
symptoms,  430 
Infantile  beriberi,  285 
convulsions,  622 
etiology,  623 
sequelae,  623 
symptoms,  624 
treatment,  624 
dysentery,   322 

paralysis.  111.     See  Poliomyelitis. 
Infections,  carriers  of,  153 
pyogenic,  47 
specific,  3 
Infectious  jaundice,  125 
Influenza,  89 
bacillus,  89    . 
complications,  92 
diarrhea  in,  93 
meningitis  in,  94 
nephritis  in,  94 
symptoms,  90 
treatment,  91 
types,  90 
vomiting  in,  93 
Insects  as  typhoid  carriers,  6 

parasitic,  140 
Insolation,  444 
Insomnia  in  hysteria,  599 

in  neurasthenia,  581 
Intercostal  neuralgia,  705 
Intermittent  claudication,  711 
etiology,  711 
symptoms,  711 
treatment,  712 
fever,  205 
Internal  anthrax,  102 

cerebral  pachymeningitis,  652 
hydrocephalus,  655 
Interstitial    form   of   nervous   syph- 
ilis, 687 
Intestinal     antiseptics     in     typhoid 
fever,  16 
distomiasis,  129 

hemorrhage  in  typhoid  fever,  19 
perforation   in  typhoid   fever,   17 
Intubation,  60 
indications,  60 


Intubation,  technic,  60 
lodids  in  arthritis,  554 
Irregular  gout,  502 
Irritant  poisons,  408 
Itch  mite,  140 
Ixodiasis,  141 

Janeway's  diabetic  diet  lists,  526,  et 

seq. 
Jaundice,  infectious,  125 

treatment,  125 
Jigger,  143 
Joint,  bleeder's,  541 

Kala-azar,  352 

Kala  dukh,  352 

Keloid,  Addison's,  713 

Kidney,  sugar  toleration  of,  453 

tuberculosis,  76 
Klebs-Lofiler  bacillus,  51 
Klumpke's  paralysis,  703 
Koch,  vibrio  of,  256,  261,  263,  265 
Kotaw^en,  366 

La  grippe,  89.    See  Influenza. 
Landry's  paralysis,  683 
Langhans'  cells,  195 
Laryngitis  in  typhoid  fever,  21 
Late  rickets,  476 
Lateral  sclerosis,  669 
amyotrophic,  676 
etiology,  676 
pathology,  676 
symptoms,  676 
treatment,  676 
diagnosis,  670 
etiology,  669 
symptoms,  669 
treatment,  670 
Laverania    malariae,    205,    215,    219, 

225 
Lead  colic,  421,  423 
poisoning,  acute,  421 
symptoms,  421 
treatment,  422 
poisoning,  chronic,  421 
symptoms,  421 
treatment,  422 
Legs,  elephantiasis  of,  394 
Leishman-Donovan  bodies,  353,  354 
Leishmaniasis,  352 
complications,   357 
diagnosis,  357 
differential  diagnosis,  358 
etiology,  353,  354 
history.  352 
jiathology,  353 
prophylaxis,  359 
symptoms,  356 


7Z2 


INDEX. 


Leishmaniasis,  synonyms,  354 
transmission,  354 
treatment,  358 
Leontiasis  ossea,  717 
symptoms,  717 
treatment,  717 
Lepra  cells,  195      .  - 
Leproma,  histology  of,  196 
Leprosy,  187 
anesthetic,  188,  199 
clinical  forms,  197 
etiology,  187,  191 
hypertrophic,  188,  197 
incidence,  190 
incubation  period,  194 
mixed  type,  188,  201 
nodular,  197 
pathology,  195 
prevention,  204 
prognosis,  202 
symptoms,  197 
transmission,  191,  195 
treatment,  202 
tubercular,  188,  197 
types,  187 
Leptomeningitis,  acute  cerebral,  653 
diagnosis,  654 
etiology,  653 
pathology,  653 
symptoms,  653 
treatment,  654 
spinal,  665 
etiology,  665 
pathology,  665 
prognosis,  666 
symptoms,  666 
treatment,  666 
Lipomatoses,  478 
Lips,  cracking  of,   in   scarlet   fever, 

173 
Litigation  hysteria,  602,  603 
Little's  disease,  668 
Locally  acting  emetics,  413 
Low^er    motor    neuron    diseases    of 

spinal  cord,  670 
Low-grade  beriberi,  285 
Lumbar  puncture,  96 
Luminal  in  epilepsy,  622 
Lymph  diarrhea,  390 
scrotum,  389 
treatment,  389 
Lymphangitis,  fdarial,  390 

treatment,  391 
Lymphatic  varix,  384,  385,  386 

Mahamari,  366 
Malaria,  205 

acute,  217 

algid,  223 


Malaria,    anopheles    and,    209,    210, 
216,  219,  237 
benign  type,  213 
chronic,  225 
complications,  226 
diagnosis,  227 
etiology,  205,  215 
geographical  distribution,  214 
history,  205 
malignant,  213 
parasites,  205,  206* 

classification,  212 

double  tertian,  213 

life  cycle,  206 

pigmented,  213 

quartan,  213 

quotidian,  213 

tertian,  213 
pathology,  216,  217,  218 
pernicious,  223 

algid  type,  223 

cardiac  type,  223 

cerebrospinal  type,  224 

diaphoretic  type,  223 

gastro-intestinal  type,  224 

hemorrhagic  type,  224 

pulmonary  type,  223 

scarlatinal  form,  224 
prognosis,  228 
prophylaxis,  235 
quartan,  213,  219 
quinin  in,  229,  231 
quotidian,  213 
reinfection  in,  225 
relapses,  225 
sequelce,  226 
subtertian,  213,  219,  222 
symptoms,  213,  219 
synonyms,  205 
tertian,  213,  219,  221 
treatment,  229 
types,  205,  213 
Malignant  edema,  102 
malaria,  213 
pustule,  102 
yellow  fever,  244 
Mallein,  101 
Malta  fever,  250 
distribution,  251 
etiology,  250,  252 
history,  251 
incubation,  253 
para-,  254 
prognosis,  255 
prophylaxis,  251,  255 
sequete,  254 
symptoms,  253 
synonyms,  250 
treatment,  255 


INDEX. 


733 


Mansfield  wafers,  549 

Marsh  fever,  205 

Massage  in  arthritis,  556,  557 

in  hysteria,  595 

in  neurasthenia,  584,  585 

in  obesity,  496 
Masticatory  myospasms,  639 

treatment,  639 
Mastoiditis   in   scarlet   fever,    175 
Measles,  179 

bronchopneumonia  in,  182 

dissemination,  179 

etiology,  179 

German,  183 
diagnosis,  184 
incubation,   183 
symptoms,  183 
treatment,  184 

incubation,  180 

symptoms,  180 

treatment,  181 
Mediterranean  fever,  250 
Melanin,  206 
Meningeal  hemorrhage  (spinal),  678 

etiology,  678 

symptoms,  678 

treatment,  679 
Meningitis,  epidemic,  95 

in  influenza,  94 

in  pneumonia,  41 

in  typhoid  fever,  24 

tuberculous,  70 
Meningococci,  95 
Mercurial  poisoning,  415 

chronic,  4l6 

pathology,  415 

symptoms,  415 

treatment,  416 
Mesenteric  tuberculous  adenitis,  72 
Metabolism,  definition  of,  449 

diseases  of,  449 
Methyl  alcohol  poisoning,  442 
Micrococcus  melitensis,  250,  251,  252 

paramelitensis,  254 

rheumaticus,  113 
Migraine,  612 

etiology,  612 

symptoms,  613 

treatment,  613 
Miliary  actinomycosis,  127 

fever,  149 

symptoms,  149 
treatment,  150 

tuberculosis,  69 
Milk  as  typhoid  carrier,  6 

diet  in  typhoid  fever,  9 

sickness,  146 
symptoms,  146 
treatment,   147 


Mineral  salts  in  metabolism,  453 
Morphea,  713 
Morphin  habit,  434 

treatment,  435 
Morphinism,  434 
treatment,  435 
Mosquito  and  dengue,  247 
and  malaria,  209.    See  Anopheles, 
and   yellow    fever,   239,   240,   241, 
246 
Motor  neuron  diseases,  lower,  670 

upper,  667 
Multiple  neuritis,  696 
etiology,  696 
symptoms,  697 
treatment,  697 
sclerosis,  684 
etiology,  684 
pathology,  684 
symptoms,  684 
treatment,  684 
Mumps,  110 
symptoms,  110 
treatment,  111 
Muris  ratti,  326 

Muscular  atrophy,  progressive,  674 
diagnosis,  675 
etiology,  674 
pathology,  674 
symptoms,  674 
treatment,  675 
progressive  neuritic,  686 
etiology,  686 
pathology,  686 
prognosis,  687 
symptoms,  686 
treatment,  687 
Muscular  dystrophies,  685 
etiology,  685 
pathology,  685 
prognosis,  686 
symptoms,  685 
treatment,  686 
types,  685 
Myalgia,  567 
pathology,  567 
treatment,  568 
Myasthenia  gravis,  642 
diagnosis,  643 
pathology,  643 
symptoms.  642 
treatment,  643 
Myelitis,  679 
acute,  679 
etiology,  679 
symptoms,  680 
treatment,  680 
central,  679,  680 
chronic,  679,  682 


734 


INDEX. 


Myelitis,  chronic,  etiology,  682 
pathology,  682 
symptoms,  682 
treatment,  682 
compression,  681 
etiology,  681 
pathology,  681 
symptoms,  681 
treatment,  681 
diffuse,  679 

transverse,  679,  680  , 

Myiasis,  144 
Myiosis,  144 
Myoclonus,  640 
hysterical,  640 
treatment,  640 
Myopathies,     685.       See     Muscular 

Dystrophies. 
Myospasms,  633 
facial,  633 

treatment,  634 
masticatory,  639 
treatment,  639 
saltatoric,  640 

treatment,  640 

tonic  facial,  635 

treatment,  636 

Neapolitan   fever,  250 

Necator  americanus,  289,  292,  294 

technic  for  finding,  298 
Nematodes,  136 
Neosalvarsan,  79,  84 

use  of,  81 
Nephritis  in  diphtheria,  65 

in  influenza,  94 

in  pneumonia,  38 

in  scarlet  fever,  176 

in  typhoid  fever,  23 
Nerve,  diseases  of  fifth  cranial,  699 

of  seventh  cranial,  701 
Nerves,  diseases  of  cranial,  699 
Nervous  diseases,  functional,  577 
organic,  651 

exhaustion,  578 

prostration,  578 

system,     syphilis     of,     687.       See 
Syphilis. 
Neuralgia,  698 

brachial  plexus,  704 
treatment,  705 

diagnosis,  699 

etiology,  698 

intercostal,  705 

treatment,  699 

trifacial,  700 
treatment,  701 
Neurasthenia,  578 

diet  in,  583,  585  I 


Neurasthenia,  electricity  in,  584,  585 
elimination  in,  582,  584 
etiology,  578 
exercise  in,  587 
insomnia  in,  581 
massage  in,  584,  585 
nursing  care  in,  586 
prognosis,  578 
psychotherapy  in,  588 
rest  in,  583,  584 
symptoms,  579 
motor,  580 
psychic,  581 
sensory,  579 
somatic,  582 
traumatic,  601 
treatment,  582 
medical,  588 
Neurasthenic  headache,  608 
Neurasthenoid      states,      578,      604. 

See  Psychasthenia. 
Neuritis,  694 
accompanying  arthritis,  570 
brachial  plexus,  704 

treatment,  704 
forms,  694 
local,  695 

diagnosis,  695 
etiology,  695 
symptoms,  695 
treatment,  696 
multiple,  696 
etiology,  696 
symptoms,  697 
treatment,  697 
of  dorsal  nerves,  705 
pathology,  694 
Neuropathic  arthritis,  541 
treatment,  542 
tremors,  650 
Neurosis,  fatigue,  578 

occupation,  641 
Neurotic  poisons,  409 
Nodes,  Heberden's,  569 

differentiated  from  gout,  503 
pathology,  570 
Nodular  leprosy,  197 
Nodules,  rheumatic,  115 

subcutaneous  fibroid,  570 
Nystagmus,  616 

Oatmeal  diet,  525 

Obesity,  alimentary,  477 
and  heart  diseases,  484 
and  internal  secretion,  484 
and  respiratory  diseases,  484 
baths  in,  495 
complications,  485 
diet  in,  488,  493 


INDEX. 


735 


Obesity,  endogenous,  478 

exercise  in,  495 

exogenous,  478 

hydrotherapy  in,  494 

massage  in,  496 

predisposing  factors,  482 

prophylaxis,  485 

thyroid  extract  in,  494 

treatment,  487 
Occupation  neuroses,  641 

treatment,  641 
Ogilvie's     serosalvarsan     treatment, 

691 
Oil,  chaulmoogra,  203 
Oils  as  hydrocarbons,  452 
Opium  in  diabetes,  534 

poisoning,  433 
chronic,  434 
symptoms,  433 
treatment,  433,  435 
Ophthalmia,  gonorrheal,  87 
Organic  headache.  608 

nervous  diseases,  651 
Oriental  sore,  342 

etiology,  342 

incubation,  342 

prognosis,  344 

symptoms,  343 

synonyms,  342 

transmission,  343 

treatment,  344 
Osteitis  deformans,  717 
symptoms,  717 
treatment,  718 

typhoid,  21 
Osteoarthropathy,  hypertrophic  pul- 
monary, 7l6 
Osteomyelitis,  117 
Ostitis,  typhoid,  21 
Otitis  media  in  pneumonia,  41 

in  scarlet  fever,  175 
Oxygen  in  metabolism.  456 
Oxyuris  vermicularis,  136,  137 

symptoms,  137 

treatment,  138 

Pachymeningitis,  651 
external  cerebral,  651 

diagnosis,  652 

etiology,  651 

prognosis,  652 

.symptoms,  652 

treatment,  652 
hypertrophic  cervical,  664 

etiology,  664 

pathology,  665 

symptoms,  664 

treatment,  665 
internal  cerebral,  652 


Pachymeningitis,  hemorrhagic  form, 
652 
diagnosis,  653 
etiology,  652 
prognosis,  653 
symptoms,  652 
treatment,  653 
purulent  form,  652 
Paget's  disease,  717 
symptoms,  717 
treatment,  718 
Pains,  growing.  115 
Palsy,  Bell's,  701 
diagnosis,  702 
etiology,  701 
symptoms,  701 
treatment,  702 
chronic  progressive  bulbar,  675 
symptoms,  675 
treatment,  675 
pressure,  694 
treatment,  694 
Paralysis,  acute  ascending,  683 
etiology,  683 
symptoms,  683 
treatment,  684 
acute  bulbar,  673 
etiology,  673 
symptoms,  674 
agitans,  647 
etiology,  647 
pathology,  647 
symptoms,  648 
treatment,  649 
brachial  plexus,  703 

treatment,  704 
facial,  701 
central.  701 
diagnosis.  702 
etiology.  701 
peripheral,  701 
■    symptoms,  701 
treatment,  702 
infantile,   111.     See  Poliomyelitis. 
Landry's,  683 
etiology,  683 
symptoms.  683 
treatment,  684 
Klumpke's,  703 
post-diphtheritic,  64 
spastic,  668 
etiology.  668 
symptoms,  669 
treatment,  669 
Para-Malta  fever,  254 
Paramyoclonus  multiplex,  640 
Paraplegia,  ataxic,  676 
etiolog\-,  676 
pathologj',  676 


736 


INDEX. 


Paraplegia,  ataxic,  symptoms,  677 
treatment,  677 
hereditary  spastic,  667 
etiology,  667 
prognosis,  668 
symptoms,  668 
treatment,  668 
Parasitic  arachnidia,  140 
flies,  144 
insects,  140 
Parasyphilitic    disease    of    nervous 

system,  687 
Paratyphoid  fever,  27 
Parenchymatous    form    of    nervous 

syphilis,  687,  690 
Paresis,  689 
symptoms,  689 
treatment,  690,  691,  692,  693 
Parkinson's  disease,  647 
Parotitis,  epidemic,  110.  See  Mumps. 
Passive  motion  in  arthritis,  556 
Pasteur  treatment,  145 
Pediculosis,  141 

treatment,  142,  143 
Pediculus  capitis,  141 
corporis,  142 
pubis,  143 
Perforation  of  bowel,  17 
Pericarditis  in  typhoid  fever,  22 

rheumatic,  ll4 
Perichondritis,  laryngeal,  21 
Periostitis,  typhoid,  21 
Peripheral  facial  palsy,  701 
Pernicious  malaria,  223 

types,  223,  224 
Peritonitis,  tuberculous,  74 
Pest,  366 
American,  239 
of  Havana,  239 
Pestilential  asphyxia,  256 
Pestis  minor,  375 
Petit  mal,  618 
Phantom  tumor,  592 
Phlebitis  in  typhoid  fever,  23 
Phloridzin  diabetes,  515 
Phosphorus  poisoning,  423 
acute,  423 
pathology,  423 
symptoms,  424 
treatment,  424 
chronic,  423 
pathology,  423 
symptoms,  424 
treatment,  424 
Phthiriasis,  141 
Pian,  332 

Pigmented  malarial  parasite,  213 
Plague,  bubonic,  366.     See  Bubonic 
Plague. 


Plasmodium  malariae,  205,  215,  219 

vivax,  205,  215,  219 
Pleurisy  in  pneumonia,  38,  39 
in  typhoid  fever,  22 
tuberculous,  IZ 
Plumbism,  421 
Pneumococci,  groups  of,  29 
Pneumonia,  27,  43 
catarrhal,  43 
bacteriology,  43 
etiology,  43 
in  diphtheria,  64 
in  measles,  182 
prophylaxis,  44 
symptoms,  44 
treatment,  45 
types,  43 
croupous,  27 

abdominal  distension  in,  Zl 

alcohol  in,  2>7 

arthritis  in,  40 

dilatation  of  stomach  in,  Zl 

early  recognition,  32 

empyema  in,  39 

etiology,  27 

food  in,  34 

fresh  air  in,  ZZ 

meningitis  in,  41 

mortality,  30 

nephritis  in,  38 

otitis  media  in,  41 

pleurisy  in,  38 

rest  in,  32 

specific  treatment  of,  28 

symptoms,  27 

treatment,  28,  31 

of     circulatory     disturbances, 

35 
of  crisis,  41 
of  delirium,  35 
of  fever,  34 
of  toxemia,  36 
use  of  drugs  in,  41 
in  typhoid  fever,  22 
Pneumonic  plague,  377 
Podagra,  497 
Poisoning,  406 
alcohol,  438.    See  Alcoholism. 

methyl,  442 
arsenic,  418 
acute,  418 
mortality,  419 
pathology,  420 
symptoms,  418 
treatment,  420 
chronic,  420 
pathology,  420 
symptoms,  420 
subacute,  419 


INDEX. 


737 


Poisoning,  arsenic,  subacute  symp- 
toms, 419 
carbon  monoxid,  427 
cocain,  430 

treatment,  431 
copper,  425 
symptoms,  425 
treatment,  425 
diagnosis  of,  411 
food,  443 
prophylaxis,  443 
treatment,  443 
illuminating  gas,  427 
acute,  pathology,  428 
sequelae,  429 
symptoms,  429 
treatment,  430 
chronic,  pathology,  428 
symptoms,  430 
lead,  421 
acute,  421 

symptoms,  421 
treatment,  422 
chronic,  421 
symptoms,  421 
treatment,  422 
mercurial,  415 
chronic,  416 
pathology,  415 
symptoms,  415 
treatment,  416 
opium,  433 
chronic,  434 
symptoms,  433 
treatment,  433,  435 
phosphorus,  423 
acute,  423 
pathology,  423 
symptoms,  424 
treatment,  424 
chronic,  423 
pathology,  423 
symptoms,  424 
treatment,  424 
silver,  426 

pathology,  427 

treatment,  427 

symptoms  of,  409 

tin,  426 

treatment  of,  412 

elimination   of  poison,  412 
neutralizing  poison,  414 
rendering  poison  inert,  414 
zinc,  425 

symptoms,  425 
treatment,  426 
Poisons,  406 
action,  406 
conditions  influencing,  406 


Poisons,  classification,  408 
definition,  406 
irritant,  408 
neurotic,  409 
Polioencephalitis,  679 
inferior,  674 
superior,  673 
Poliomyelitis,  acute  anterior,  111,  670 
etiology.  111,  670 
pathology,  670 
prognosis,  671 
symptoms,  671 
treatment,  672 
types,  112 
Polyarticular  gout,  502 
Polyneuritis  endemica,  273 
Polyuria,  types  and  causes,  538,  539 
Pork  tapeworm,  130 
Post-diphtheritic  paralysis,  64 
Pressure  palsy,  694 

treatment,  694 
Primary  hypertrophic  osteoarthritis, 
543 
etiology,  543 
pathology,  543 
symptoms,  543 
treatment,  545 
lateral  sclerosis,  669 
diagnosis,  670 
etiology,  669 
symptoms,  669 
treatment,  670 
progressive  polyarthritis,  559 
Progressive  bulbar  palsy,  675 
symptoms,  675 
treatment,  675 
facial  hemiatrophy,  712 
etiology,  712 
pathology,  713 
symptoms,  712 
treatment,  713 
muscular  atrophy,  674 
diagnosis,  675 
etiology,  674 
pathology,  674 
symptoms,  674 
treatment,  675 
neuritic  muscular  atrophy,  686 
etiology,  686 
pathology,  686 
prognosis,  687 
symptoms,  686 
treatment,  687 
polyarthritis,  559 
Prostration,  heat,  444 

nervous.  578 
Proteins,  450 
caloric  value,  451 
chemical  composition,  450 


47 


738 


INDEX. 


Proteins,  daily  requirement,  450 

elimination,  451 

injection  of,  553 

respiratory  quotient  for,  457 
Proteose,  injections  of,  553 
Protozoal  dysentery,  304 
Psittacosis;  146 

treatment,  146 
Psoriasis  and  gout,  503 
Psychasthenia,  578,  604 

hypothyroidism  in,  605 

prognosis,  605 

psychotherapy  in,  605 

symptoms,  604 

treatment,  605 
Psychomotor  tic,  604 
Psychotherapy  in  hysteria,  599 

in  neurasthenia,  588 

in  psychasthenia,  605 
Puerperal  convulsions,  625 

treatment,  626 
Pulex  irritans,  143 

penetrans,   143 
Pulmonary  actinomycosis,  127 

distomiasis,  128 

form  of  miliary  tuberculosis,  70 
Puncture,  lumbar,  96 
Purin  bodies,  500 

endogenous,  500 

exogenous,  500 
Purulent  pachymeningitis,  652 
Pustule,  malignant,  l02 
Pyemia,  47 
Pyogenic  infections,  47 

mortality,  48 

prophylaxis,  48 

treatment,  48 
Pyorrhea  alveolaris  as  cause  of  ar- 
thritis, 546 

Quartan  fever,  213,  219 

double,  221 

simple,  220 

triple,  221 
Quincke's  disease,  710 
Quinin  in  malaria,  229,  231 
Quotidian  malarial  fever,  213 
Quotient,  respiratory,  457,  518 

Rabies,  144 

incubation,  144 

prophylaxis,   145 

symptoms,  144 

transmission,  144 

treatment,  145 
Rachitis,  471.    See  Rickets. 

tarda,  476 
Radium  in  arthritis,  559 
Railway  spine,  600 


Rat-bite  fever,  325 . 

abortive  type,  327 

etiology,  326 

history,  325 

incubation,  326 

mortality,  328 

symptoms,  326 

treatment,  328 
Ratio,  D  :  N,  518 

Rats,  destruction  of,  in  plague,  380 
Raynaud's  disease,  etiology,  709 

symptoms,  708 

treatment,  709 
Relapsing  fever,  328 

distribution,  329 

etiology,  328,  329,  330 
.  history,  329 

incubation,  331 

mortality,  331 

pathology,  330 

prophylaxis,  332 

symptoms,  331 

synonyms,  329 

transmission,  329 

treatment,  332 
Remittent  fever,  205,  329 
Renal  diabetes,  515 
Respiratory  quotient,  457,  518 
Rest  in  hysteria,  594 

in  neurasthenia,  583,  584 
Retrocedent  gout,  504 
Rheumatic  endocarditis,  114 

fever,  113 
complications,  114 
differential  diagnosis,  116 

from  gout,  117,  503 
etiology,   113 
symptoms,  113 
treatment,  118 
by  vaccines,  120 

nodules,  115 

pericarditis,  114 
Rheumatism,  cerebral,  115 
Rheumatoid  arthritis,  567 
Rhinorrhea,  scarlatinal,  173 
Rice  extract  in  treating  beriberi,  281 
Rickets,  471 

acute,  468 

adolescent,  476 

congenital,  476 

etiology,  472 

late,  476 

pathology,  473 

symptoms,  473 

treatment,  474 
Rockv  Mountain  spotted  fever,  108 

etiology,  108,  141 

symptoms,  108 

treatment,  109 


INDEX. 


739 


Sacroiliac  arthritis,  558 
St.  Vitus'  dance,  626 
Salicylates  in  arthritis,  554 
in  gout,  511 
in  migraine,  614 
Saltatoric  myospasm,  640 

treatment,  640 
Salts,    mineral,    in    metabolism,   453 
Salvarsan,   use  of,   79,  80,  84,  328, 

332,  341,  690 
Sand  flea,  143 
Saulsbury  diet,  507 
Scarlet  fever,  165 
adenitis  in,  177 
chest  complications  in,  177 
classification  of  cases  of,  167 
complications,  173 
cracking  of  lips  in,  173 
diagnosis,  167 

duration  of  quarantine,  178 
etiology,  165 
incubation,  166 
lingual  ulcers  in,  173 
malignant,  168 
mastoiditis  in,  176 
nephritis  in,  176 
otitis  media  in,  175 
relapses,  177 
rhinorrhea  in,  173 
second  attacks,  178 
symptoms,  166 
transmission,  165 
treatment,  168 
diet,  171 
hygienic,   169 
isolation,  168 
medical,   169 
of  angina,  172 
of  albuminuria,  174 
of  arthritis,  175 
Sciatica,  706 
diagnosis.  706 
etiology,  706 
symptoms,  706 
treatment,  707 
Scleroderma,  713 
pathology,  713 
prognosis,  714 
symptoms,  713 
treatment,  714 
Sclerosis,  amyotrophic  lateral,  676 
etiology,  676 
pathology,  676 
symptoms,  676 
treatment,  676 
multiple,  684 
etiology,  684 
patholog}',  684 
symptoms,  684 


Sclerosis,  multiple,  treatment,  684 
primary  lateral,  669 
diagnosis,  670 
etiology,  669 
symptoms,  669 
treatment.  670 
Scorbutus,  463.    See  Scurvy. 
Scrotum,  elephantiasis  of,  395 
lymph,  389 
treatment,  389 
Scurvy,  463,  468 
in  adults,  463 

complications,  463 
etiology,  464 
pathology,  465 
prophylaxis,  465 
symptoms,  463,  465 
treatment,  466 
infantile,  468 

age  incidence,  469 
diagnosis,  470 
etiology,  468 
pathology,  470 
symptoms,  469 
treatment,  470 
Senile  tremors,  650 
Septicemia,  47 
Bruce's,  250 
gonorrheal,  87,  88 
melitensis,  250 
Septicemic  plague,  376 
Serosalvarsan   treatment,  691 
Serum,  antimeningococcic,  97,  654 
antitetanic,  99 
Flexner's  97,  654 
gonorrheal,  89 
sickness,  57 

treatment  of  pneumonia,  28 
Seven  days'  fever,  247 
Seventh  cranial  nerve,  701 
paralysis,  701 
diagnosis,  702 
etiology,  701 
symptoms,  701 
treatment,  702 
Sexual  hypochondria,  607 
Shattuck's  diet  for  typhoid  fever,  11 
Ship  beriberi,  468 
Sickness,  milk,  146 
symptoms,   146 
treatment,   147 
serum,  57 
Silver  poisoning,  426 
pathology,  427 
treatment,  427 
Simple  quartan  fever,  220 
subtertian.  fever,  222 
tertian  fever,  221 
Sinus,  thrombosis  of  cerebral,  657 


740 


INDEX. 


Sinusitis  as  cause  of  headache,  611 
Sleeping  dropsy,  286 
Smallpox,  156 

complications,  157 
diagnosis,  158 

from  varicella,  164 
dissemination,   156 
incubation  period,  157 
symptoms,  157 
treatment,  158 
Solution,  Benedict's,  529 
Sore,    oriental,    342.      See    Oriental 
Sore, 
throat,  gouty,  514 
scarlatinal,  172 
Spasm,  habit,  632 
of    localized    muscles,    633.      See 
Myospasms. 
Spasmodic  torticollis,  636 

treatment,  637 
Spastic  paralysis,  668 
etiology,  668 
symptoms,  669 
treatment,  669 
paraplegia  (hereditary),  667 
etiology,  667 
pathology,  668 
symptoms,  668 
treatment,  668 
Specific  infections,  3 
Spina!  cord  diseases,  666 
combined  system,  676 
diffuse,  678 

lower  motor  neuron,  670 
upper  motor  neuron,  667 
leptomeningitis,  665 
etiology,  665 
pathology,  665 
prognosis,  666 
symptoms,  666 
treatment,  666 
meningeal  hemorrhage,  678 
etiology,  678 
symptoms,  678 
treatment,  679 
Spine,  chronic  arthropathies  of,  568 
concussion  of,  600 
railway,  600 
typhoid,  26 
Spirillum  fever,  329 

of  cholera,  265 
Spirocheta  duttoni,  329 
obermeieri,  329 
recurrentis,  329,  330 
Splenic  fever,  102 
Sponge  bath,  14 
Spotted  fever,  95 
Sprue,  344 
diagnosis,  349 


Sprue,  differential  diagnosis,  350 

distribution,  345 

etiology,  346 

history,  345 

pathology,  346 

prognosis,  350 

prophylaxis,  352 

symptoms,  346 

synonyms,  344 

treatment,  350 
Staphylococcus  citreus,  569 
Stegomyia  calopus,  239,  240,  241,  246 

fasciata,  239,  247 
Still's  disease,  569 

pathology,  569 

treatment,  569 
Stock  vaccines,  551 
Stomach,    dilatation    of,    in    pneu- 
monia, Zl 

in  typhoid  fever,  20 
Stomatitis,  mercurial,  417 
Streptococcus  erysipelatis,  65 

hemolyticus,  545 

viridans,  545 
Streptothrix  actinomyces,  126 
Subarachnoid  injections,  technic,  84 
Subcutaneous  fibroid  nodules,  570 
Subtertian  fever,  213,  219,  222 

double,  223 

simple,  222 
Sugar  toleration  of  kidneys,  453 
Swift-Ellis  serosalvarsan  treatment, 

691 
Sydenham's      chorea,      626.        See 

Chorea. 
Symmetrical  gangrene,  709 
Symptom,  Chvostek's,  645 

Erb's,  645 

Hoffman's,  646 

Trousseau's,  645 
Symptomatic  diabetes  insipidus,  538 
Syndrome,  Frohlich's,  478 
Syphilis,  76 

and  marriage,  85 

cerebrospinal,  84 

congenital,  76,  11 ,  85 

diagnosis,  79 

etiology,  76 

iodid  of  potassium  in,  83,  84 

mercury  in,  81,  82 

neosalvarsan  in,  1^,  81,  84 

of  nervous  system,  687 
diagnosis,  688,  689 
exudative  form,  687 
forms,  687 
interstitial  form,  687 
Ogilvie's     serosalvarsan     treat- 
ment, 691 
parenchymatous  form,  687,  690 


INDEX. 


741 


Syphilis   of   nervous    system,    prog- 
nosis, 689 

serosalvarsan  treatment,  691 

Swift-Ellis'  serosalvarsan  treat- 
ment, 691 

syinptoms,  687 

treatment,  689 
primary  stage,  11 
prophylaxis,  78 
salvarsan  in,  79,  80,  84 
secondary  stage,  11 
stages,  n 
tertiary  stage,  11 

treatment,  83 
transmission,  Id,  11 
treatment,  78 
Syringomyelia,  682 
pathology,  682 
symptoms,  682 
treatment,  683 

Tabes,  688 

symptoms,  688 
treatment,  690,  692,  693 

mesenterica,  71 
treatment,  72 
Table  of  normal  weights,  479 
TjEnia  echinococcus,  134,  135 

solium,  134 
Tasniasis,  somatic,  134 
■     treatment,  135 
Tapeworm,  130 

beef,  130 

diagnosis,  132 

fish,  130 

pork,  130 

prophylaxis,  132 

symptoms,  130 

treatment,  133 
Teeth  as  source  of  infection  in  ar- 
thritis, 545 
Tertian  fever,  213,  219,  221 

double,  222 

simple,  221 
Tests,  Barany,  616 
Tetanus,  98 

bacillus,  98 

etiology,  98 

following  vaccination,  162 

neonatorum,  99 

Symptoms,  99 

treatment,  99 
Tetany,  644 

etiology,  646 

prognosis,  646 

symptoms,  644 

treatment,  647 
Thermic  fever,  444 

prophylaxis,  444 

treatment,  445 


Threadworms,  136 
Throat,  gouty  sore,  514 

scarlatinal  sore,  172 
Thrombosis  of  cerebral  sinuses,  657 
symptoms,  657 
treatment,  657 
of  spinal  cord,  679 
Thymus  gland  in  arthritis,  555 
Thyroid  gland   in  arthritis,  554 
in  cretinism,  486 
in  epilepsy,  622 
in  obesity,  494 
Tic,  631 
convulsif,  604,  631 
douloureux,  700 
treatment,  701 
etiology,  631 
psychomotor,  604 
symptoms,  631 
treatment,  631 
Tick  disease,  141 
Tin  poisoning,  426 
Tonic  facial  myospasm,  635 

treatment,  636 
Tonsillitis,  acute,  123 
bacteriology,  123 
treatment,  123 
Tonsils  as  primary  focus  of  infec- 
tion in  arthritis,  547 
Torticollis,  spasmodic,  636 

treatment,  637 
Towns'    treatment    of    mnrnhinism 

435 
Towns-Lambert    treatment    of    co- 

cainism,  431 
Toxemia,  47 

in  pneumonia,  36 
Toxic  headache,  610 
Toxicology,  406.    See  Poisons. 
Tracheotomy,  62 

technic,  62 
Transverse  myelitis,  679,  680 
Traumatic  epilepsy,  620 
hysteria,  600 

hystero-neurasthenia,  601 
neurasthenia,  601 
Trembles,   146 
Tremors,  familial,  650 
functional,  649 
hereditary,  650 
idiopathic,  650 
neuropathic,  650 
senile,  650 
Treponema  pallidum,  76,  79,  687 

pertenue,  334,  335 
Trichiuc-e,  136.  138 
Trichiniasis,  138 
prophylaxis,   140 
symptoms,  139 


742 


INDEX. 


Trichiniasis,  treatment,  140 
Trifacial  neuralgia,  700 
treatment,  700 
paralysis,  700 
Triple  quartan  fever,  221 
Tropical  apthse,  344 

diarrhea,  344 
Trousseau's  symptom,  645 
Trypanosoma  cruzi  Chagas,  287 
Trypanosoma  gambiense,  286 

rhodesiense,  286 
Try^panosomiasis,  286 
diagnosis,  288 
distribution,  286 
etiology,  286 
history,  286 
incubation,  287 
in  South  America,  287 
pathology,  287 
prognosis,  289 
prophylaxis,  287 
symptoms,  287 
synonyms,  286 
treatment,  289 
Tubercular  leprosy,  188,  197 
Tuberculin,  use  of,  73 
Tuberculosis,  68 

following  pertussis,  108 
general  miliary,  69 
meningitic  form,  70 
prophylaxis,  70 
pulmonary  form,  70 
treatment,  69 
typhoid  form,  69 
general  treatment,  68 
genito-urinary,  75 
incidence,  68 
of  bladder,  75 
of  kidney,  76 
Tuberculous  adenitis,  71 
bronchial,  72 
cervical,  72 
general,  71 
mesenteric,  72 
meningitis,  70 
peritonitis,  74 
symptoms,  75 
treatment,  75 
pleurisy,  Ti 
symptoms,  73 
treatment,  73 
with  effusion,  74 
Tumor,   of   brain,   662.     See   Brain 
Tumor, 
phantom,  592 
Tympanites  in  pneumonia,  Zl 
Typhoid  bacillus,  3 
carriers,  6 


Typhoid  fever,  3 
alcohol  in,  16 
appendicitis  in,  25 
bilious,  329 
blood-count  in,  18 
Brand  bath,  12 

contraindications,  13 
bronchitis  in,  21 
calomel  in^  15 
cardiac  weakness  in,  22 
cholecystitis  in,  24 
cold  affusion  in,  13 
complications,  17 
control  of  temperature  in,  12 
cystitis  in,  23 
delirium,  23 
diet,  9.  11 

dilatation  of  stomach  in,  20 
drugs  in,  15 
endocarditis  in,  22 
etiology,  3 
food  in,  9 
furunculosis  in,  24 
hemorrhage  in,  19 
intestinal  antiseptics  in,  16 
laryngeal  perichondritis  in,  21 
laryngitis  in,  21 
meningitis  in,  24 
milk  in,  9 
nephritis  in,  23 
nursing  in,  8 
ostitis  in,  21 
pathology,  3 
perforation  in,  17 
pericarditis  in,  22 
periostitis  in,  21 
phlebitis  in,  23 
pleurisy  in,  22 
pneumonia  in,  22 
prophylaxis,  4 
regulation  of  bowels  in,  14 
rest  in,  8 

Shattuck  diet  in,  11 
sponge  bath  in,  14 
treatment,  7 

during  convalescence,  26 
of  diarrhea,  15 
water  in,  14 
Typhoid   form  of  influenza,  91,  95 
of  miliary  tuberculosis,  69 
inoculation,  7 
spine,  26 
vaccination,  7 
vaccines,  26 
Typhus  fever,  359 
complications,  363 
diagnosis,  364 
differential  diagnosis,  364 
etiology,  361,  362 


tNDE}C. 


743 


Typhus  fever,  history,  359 

mortality,  363 

pathology,  362 

prophylaxis,  365,  366 

symptoms,  362 

synonyms,  359 

transmission,  361 

treatment,  364 
Typhus  icteroides,  239,  329 

recurrens,  329 

Ulcers  of  tongue  in  scarlet   fever, 
173 

Uncinariasis,  289.     See  Hookworm 

Infection. 
Undulant  fever,  250 
Upper  motor  neuron  diseases,  667 
Urea,  451 

Uremia  differentiated  from  acid  in- 
toxication, 521 
Uremic  headache,  609 
Uric  acid,  451,  499 

diathesis,  497 

in  blood,  452 
Uricemia,  500 

types,  500       _       _ 
Urine  disinfection  in  typhoid  fever, 

5 
Urticaria,  giant,  710 

Vaccination,  153,  159,  160 

antityphoid,  7 

complications,  162 

course,  161 

technic,  160 
Vaccines,  autogenous,  50,  51,  551 

dosage,  552 

gonorrheal,  89 

in  infectious  arthritis,  551 

rheumatic,  120 

stock,  551 

typhoid,  26 

whooping-cough,  106 
Vaginitis,  gonorrheal,  87 
Varicella,  162 

complications,   163 

diagnosis,  164 

from  smallpox,  164 

infectiousness,  163 

symptoms,   163 

treatment,  165 
Varioloid,  160 

treatment,  160 


Varix,  lymphatic,  384,  385,  386 
Vasomotor  and  trophic  diseases,  708 
Vertigo,  615 

artificial  production  of,  616 

diagnosis  of  cause  of,  616,  617,  618 

etiology,  616 

symptomatic,  615 

treatment,  618 
Vibrio  of  Koch,  256,  261,  263,  265 
Villous  arthritis,  chronic,  568 
Vitamins,  450,  454 
Vomiting  in  influenza,  93 
Vulva,  elephantiasis  of,  395 

Wafers,  Mansfield,  549 
Wassermann  test,  83,  85 
Water  in  metabolism,  456 
Weights,  table  of  normal,  479 
Weil's  disease,  125 
Wet  beriberi,  277,  279 
Whooping-cough,   104 

diagnosis,   105 

prophylaxis,  104 

symptoms,  105 

transmission,  104 

treatment,   106 

vaccines,   106 
Wood  alcohol  poisoning,  442 
Wool-sorters'  disease,  102 
Worm,  tape-,  130 

thread-,  136 

Yaws,  332 
Yearly  boil,  342 
Yeki,  366 
Yellow  fever,  239 

differential  diagnosis,  245 

etiology,  240 

history,  239 

incubation  period,  243 

malignant,  244 

mortality,  244 

pathology,  241 

prophylaxis,  246 

stegomyia  calopus   and,   239,  240, 
241,  246 

symptoms,  243 

synonyms,  239 

treatment,  245 

Zinc  poisoning.  425 
symptoms,  425 
treatment,  426 


